HomeMy WebLinkAboutMiscellaneous - 33 BEECH STREET 4/30/2018 (2)N
Air Quality Experts, Inc.
3 Brentwood Avenue, Salem, New Hampshire 03079
Christopher Thompson NH (603) 894-6465 • MA (617) 734-8700
MAY 21, 1992
NO. ANDOVER BOARD OF HEALTH
120 MAIN STREET.
NO. ANDOVER, MA 01845
DEAR SIR:
r
Asbestos Removal
Residential • Commercial • Industrial
ENCLOSED PLEASE FIND COPIES OF D.E.P. AND D.L.I.NOTIFICATIONS
FOR ASBESTOS ABATEMENT WORK TO BE PERFORMED ON JUNE 23, 1992.
IF YOU HAVE ANY QUESTIONS PLEASE CALL!!
SINCERELY,
CHRISTOPHER THOMPSON
PRESIDENT
DEP
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention — Air Quality
BWP AQ 04 Asbestos Removal Notification
BWP AQ 06 Notification Prior to Construction or Demolition
Permits for Asbestos
......... ..., Applicability
Permit No ............:............ i
i Received Date ...................
Reviewer Demolftion/Renovation operations involving asbestos- renovation operations and demolition/renovation operations
Permil oaPpr. oDented containing material (ACM) and general Demolftion/Renovation involving ACM is required under 310 CMR 7.09 (2) and 310
Decision Da1e•......••......••... operations are regulated by the Department of Environmental CMR 7.15 (1) (b) twenty (20) days prior to any work being
Protection (DEP), Bureau of Waste Prevention —Air Quality performed. The following information is re.quire.d.pursuant to
Division, under Regulations 31-0 CMR 7.00, 7.09 and 715. 310 CMR 7:15.
Notification to the REGIONAL -OFFICE of general demolition/
gev. 1/91
Telephone
13 Asbestos Removal Description
1. Asbestos Contractor g L E M rJ 1-i 0 3 0 7
City/rown
...........: .'..K...:...4�..9..! .T .
`/....... F.x. R.r..�:.................... 6 3 �' 4 `� 6 `T G s
Nana? --—_.-_-----
Telephone
.................... O U G 1 6
Addressrkpartrnenro/LahorandIndustriesLicense/ —
Page 1 of
General Project Description
1. Facility
c v . .........................................
3. On Site Manager
Name.•
................. .........�...F....c...l..i ST.
.. 33
..........................................................................................
Address
....................................:...........
Name
City/Town
Address
.................... .P....�..8.�;....:....y..`..1...............................
.............................................................................................................
Telephone
City/Town
SIZE - �
/ 0 (i
..............................................................................
...............................................................................................................
Telephone
syuareleel
Z :::.....................................................
4. General Contractor
Number d lloors
Was the Facility built prior to 1980? C' Yes ❑ No
Name --- —
ES .oEn1c Q
Address --
CunenforPdoru olFaolOtywn
/
- ____._..
Clty/fo
Is the Facility Occupied? Yes ❑ No
Is this Facility Owner -Occupied Res' nGal with 4 units or less?
- Telephone
Yes O No
2. Facility Owner
Does this project involve the removal and/or alteration of
�q
5A..."'.l. C............................
any Asbestos Containing Material (ACM) as defined and
........ ........................
applied In 310 CMR 7.00 and 7.157?
Namr
VB es ❑ No
............................................................................................................
Address
If Yes, complete Sections C and D
If No, complete Sections D and E.
C..iry/Io........K.n................................................................................................
Telephone
13 Asbestos Removal Description
1. Asbestos Contractor g L E M rJ 1-i 0 3 0 7
City/rown
...........: .'..K...:...4�..9..! .T .
`/....... F.x. R.r..�:.................... 6 3 �' 4 `� 6 `T G s
Nana? --—_.-_-----
Telephone
.................... O U G 1 6
Addressrkpartrnenro/LahorandIndustriesLicense/ —
Page 1 of
hfa=chusetts Department-of Environmental Protection
Bureau of Waste Prevention — Air Quality
Tra`i��� n.s. mitt.t....al'..A' .......`;
BWP AQ 04 Asbestos Removal Notification -
' BWP AQ 06 Notification Prior to Construction
or Demolition ........................
facility ID (�f knor,
Permits for Asbestos
2. On-Site Supervisor
7. Description of techniques used for estimation
e i s•T o P 1-1 6eg, -r— A o .M P .': o f
_r); F,
Narm SS'
--. ----
Depatven/ofLabor and ndusti sCq1tidatlon
3. Hygie ist
Nalm-----
4. Specific Worksite Locations(s) (i.e. Building name,
8. Asbestos Removal
number, wing, floor, room, tunnel.)
Z Z
L,
............................ .................................... :......................... ............. .....
Dale
Qz
............................................................................................................
EndDafe
5. Is the job being conducted indoors or outdoors?
Ho of Operation
daytime ❑ evening ❑ night
/1✓Do 0 2S'------------------
Day Operation -
Mon. — Fri. ❑ Sat.— Sun.
(Note:Any-dhanges in these dates must be reported to the
6. Estimated amount of Each type of ACM to-be dandled
appropriate regional office. If a removal is postponed for
more than thirty (30) calendar days separate notification will
be required.)
Linear/ Square Feet
boiler, breeching, duct,
9. Describe the asbestos removal procedures t e used.
tank surface coatings /
❑ glove bag ❑ enclosure full containment
❑ cleanup ❑ encapsulation ❑ disposal only
thermal, solid core pipe insulation/
...........................
❑ other-please describe
corrugated or layered
................................................................................................................
paper pipe insulation/
10. Transporter of asbestos-containing waste material from site
to temporary storage site (if necessary) to final disposal site
insulating cement /
spray-on fireproofing
::......................................................................................................
Name
_
trowel/sprayer coatings /
............................
........................................................................................................... .
Address
.
cloths, woven fabric /
............................
.............................................................................................................
cfryRown
transite board, wall board /
............................
...................................................................
relepnone
other— please describe /
Total in Linear Feet /
Total in Square Feet / �/D
...................I........
Rev.1/91
Page 2 of 4
........
Massachusetts Deparbit.,il ul inriiu,iL;,, ,.a! Protection /��� �Jl 2 -
Bureau of Waste Prevention —Air Quali ` r
tY Transmittal
BWP AQ 04 Asbestos Removal Notification
BWP AQ 06 Notification Prior to Construction or Demolition
� Facility lD
Permits for Asbestos
11. Transporter of asbestos -containing waste material from
removalAemporary storage site to final disposal site
/9l.R Q UAL
Nam
SbeelAddress
v3o�9-
Clty/70wn
6o3 89N 6N6S
Telephone
12. Refuse transfer station facility and owner (if applicable)
Name
13. Final Disposal Site
.......... "..I ..!�...1.. (--..`�...... .!Y. ?. �.!...l-.1..... ...................
Name 2
... c �a rs r�� J E� �....ti..='...........
Address
I o<- �i E i E li r j �...�
..................................:...........�................................................
cRyAom
_.... _...... . o.. ........ ................... d.3.... 8 ... ....................
Telephone
�1!A....�.......M /�.nl.Fl..G..EM EI�IT.........h`..:...-
owners Name
(Note: Disposal of ACM must comply with the Solid Waste
Divisions regulations 310 CMR 19.00.)
14. Emergency Asbestos Removal Operations
DEP official who evaluated the emergency:
Address
......................................................:....................................................................................................................................................................
CiVTown Name
..........................................................................................................................................................................................................................
Telephone TIlle
...........................................................................................................................................................................................................................
Owners Name Authority
(Note: Transfer Stations must comply with the Solid
Date olklhorizalian
Waste Division regulations 310 CMR 18.00.)
General Demofilion/Renovation Description
1. D e m ol Rio n/Renovation Contractor 4. Was the facility, surveyed for the presence of asbestos
containing material (ACM)?
Name —-- ❑ Yes ❑ No
If yes, who Conducted the Survey?
Address
...............................................................................................................
Name
C/y/rown -- —��
..............................................................................................................
_ Oeparhnenl ollabor and lnduslries Cerlilicalion /
Telephone
2. On -Site Supervisor 5. If yes, who conducted the survey?
................................................................................................................
Name
Name
3. Identify the specific.Worksite Location(s):
Department of Labor and Indusldes Certilicalion /
;•6. Demolition/Renovation Asbestos Removal
................................................................................................................
Slar1 Dale End Dale
Rev. 1/91
Page 3oi4
Mawachusetts Department offnvlranmental Protection
Bureau of Waste Prevention — Air Quality `Transmittal i
BWP AQ 04 Asbestos Removal Notification ---
BWP AQ 06 Notification Prior to Construction or Demolition ..
� Facility lD (i( kno�.��,
Permits for Asbestos
7. Describe the demolition/renovation procedures to be 8. Emergency Demolition/Renovation Asbestos Removal
used: Operations
State or local official who evaluated the emergency:
(Note. Demolition/Renovation Operations must comply
with 310 CMR 7.09 to control emissions to prevent a
condition of air pollution.)
Title
Authority
Date o/Authodration
(General Statement: If asbestos -containing material is unexpectedly found or damaged during a Demolition/Renovation
operation, all responsible parties must comply with 310 CMR 7.00, 7.09, 7.15 and Chapter 21 E of the General Laws of the
Commonwealth. This would include but would not be limited to filing an asbestos removal notification with the Department
and/or a notice of a releaseRhreat of release of a hazardous substance to the Department if applicable.)
Certification
certify that I have examined the above and that to the
best of my knowledge it is true and complete. The
signature below subjects the signer to the general statutes
regarding a false and misleading statement(s).
C..................................................:::.....:...,............................, .;......1..................................:..........................
Print Name AuN dW Slpnalure . .
)2l3 E 5 i r� F N !% l} .k .�..� . E i 1� T /V
l.:.............4t ..:..:.................. :: 1�.....:5�.......................................
Pos!lion/fiUe ._--RepiesenD'n
........
z
............................................................................................
Date
Rev. 1/91
Page 4 of
• � , fly : ircri z fi;czzlth of 114• MSSCIC411scils
DEPARTMENT OF LABOR AND INDUSTRIES
DIVISION OF "INDTJS- RIAL SAFETY
NCTIFICATION OF ASBESTOS WOPX
(In. -accordance with the provisions of N.C.L. C. 14.9
All sections of .� . 45-6F and 453 C::R 6.12)
this. .ora must' be completed in order to comply wi tL-
tl:e notjfjcation requireraents of 453 CAR 6.12
TEN DAY PRrOR NOTSFICATICN IS REQUIRED OF AArY-ABA7Z1-j NT pRW CT
GIcATER THAN THREE (3) LINEAR OR SJUA.R.r FEET
DLI FILE NUMBER
Ccrtractor perfornir_g project- AIR QUALITY EXPERTS, INC.
License ,.'AC 000167
Do preva,ilicg rates of waged ..apply to this Project as re
cruder K.C.L e. 149, X26, 27 or 27F? (circle ore) gctired
YES
Address of..P►-c
Y
Building Name (if any) /%
Street Address
C1 t y �D /Vg a ,,c- a
Phone jr` U Z
F y�i
Project tC-NbV:AATXON
ype (circle oneJ. "�`
DEMOLITION RgpAXR
OTB R
`j If 'Other•• selected, . please explain
Asbestos Activity: (circle "J- E11'CADSULATION
ENCLOSURE.
ASSOCSATZD PROJECT
N.OvAL ,
Indicate amount of. asbestos surface on Pipe or ducts
OR LINEAR FEET
pipes or ducts to beremoved asaesto; surface on structures
enclosed or encapw1ated o�:er than
1�n �UpRE
Start Cate G "� .? � 7 PcPT
an ..�
--=-- - pm----- � _ weekends? iJ o
Couple'ion Date
11-23'9
Project Supervisor Name
CHRISTOPHER THOMPSOP"
AsbestosAnal Ccrt:it`.icate // SF06466
ytical Lab Name FINAL CLEARANCE 1►d� L,ys certificate /J AA00008
"ane 6 Address of disposal site(sJ T ----BEY LAdDFILL �- 5
90 R0CHESTEP R NECK RD.
0049al1 ROCHESTER, NH 03867
ll
or, vcrbal7 V'� � 1 i /• �/l1 �
ConsacGor•a workers, COMMERCIAL UNION
Policy Number .�+ CM91H'548299
?acilSty owner �r �!
Addresa'
City State
Dk scr_pC_0JX of work practices ta.-be~ f4b3lowed:
ALL WORK WILL BE DONE IN -.COMPLIANCE WITH LOCAL, STATE
AND!FEDERAL REGULATIONS._
ipt3oa of decantamiratfon_system;sj to be used
:escr.ipcicd of handltng/disposal methods to comply with 453
CPR 6.10(21 !qJ
WET REMOVAL INTO EMIL POLY DOUBLE ASBESTOS LABELED BAGS.
'-me and address of transporter(s) if other than the' asbestos contractor:
undersigned hereby states, under the penalties of perjury, that he/she has
:ad and understood the Coraronwealth of Massachusetts Regulations for the
uroval; COntalnment or Encapsulation of Asbestos, 453:61!!R 6%00, and that the
Xornaeli i' ntained in this notification is true and correct to the best of
sjhcrk•-nowledge and belief.
.Signed. dt4 J ;ijy9 °SG•yL
Title:_`�%�%ZI<S! n F irT"
Ccmpany: (f,l}.LISr
3 2LrU T' uJ ot, Li
'15c return this form to: S•AL L/c'L . ru` .�"�'• a•3v ?� :
Asbestos Control Tec;,nical Services
& iaitTent of Labor and rndustiieS•• i I
Division o. Industrt.�.l._3.6feCy'
300. camhrialc..Str�et, Room'2101 Dos ca, M 02202
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