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Commonwealth of Massachusetts
Asbestos Notification form — ANF -001
Asbestos Abatement Description
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ti f11y ` x v F� (.1A1
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I. Facility location: -
II.
Eugene Avrett . 6 '
Andover Street
t;itn>aucnfatf>w +rantr AOAw
!I _... ....,N.• ,. No. Andover, MA .. .. '•01845
I. All sections of this (617) 495-7423
form must be compbted, tap/fowi 4000 [ Aoone
in order to complywo Basement
the Drip m nta l of • fMrt�1 k M tiaNsile lant>an7 Aullding am, /, wing, hoar, room
Environmental ��� �
1"Ukeholocart notification31p, is the facility occupied? CM Yes 0 No
rerwiremehs of 310 CMji Y P r •
7.15 (Jen wnrkigp -
pr4rntarilraUong I Asbestos Contractor.
requYedolanyabatarrent Asbestos free, Inc. 42.. Broadway'
p►ajedi; aro the
D m
ent of
Namr
ut
p uba
A&nxs
and ti Nuscation equ Wakefield, MA 01880 (781) 245-4403
'
notification requwemerts .
of 453 CMA 6.12 (ten Ory/lonn 7na>t
days prianoti!icalionis"' "' AC000133 Written
requiied dANI'
abarernertt project greater allicense / Ccwtrrd Tjy1(wrineMeroaQ
Ow throe low or
square W. 4. On -She Project Supervisor/Foreman: r
2. Submit OrigimlForm . Paul T. Scott AS 53032
To: µii DUCw dafi'onI
Commonwealth of
Massachusetts 5, project Monitor,
Asbestos Prograrp ; /
P-0-1. 120087 q t: N A
Postop, MA 0211?• Nun
0097 AUC419RCat4a/
� . ,
6. Asbestos Analytical Lab:
I This lormmaybe Environmental Remediation Services AC000122
used for notifying the
U.S. EnviiMurual Nun AUCorOGc�an/
Protection Agency Region •. .
IolasbestosdemolitioN 7. Projectstandatd �� endda4_ _§fi_ specdicworkhours(Mon.•Fri.) 7-5 -(Sat. Sun.)
renovation operations -
subjea to NESwW$ (/0 °
CFR Subpart M). $. What type of project is this? (circle one): abrndlcm �r�pal� mcrori r;pt
raalWlUN04p 9. Describe the asbestos abatement procedures to be used (circle): pbhG�g snulasun IMI ur040
tnuasonl sncaµsalxion aksposirowl A wflr w)
e"nio0iy 10. Is the job being conducted ® indoors 0 outdoors ?
Now ,,, W,p 11. Total amount of each type of Asbestos Containing Materials (ACM) to be handled on pipes or ducts (linear tt.) 300 or other
surfaces (square ft.) to be removed, enclosed or encapsulated:
linear/square Leet
boiler, breaching, dud, tank surface coatings... _/ Owmal, sold cote pipe iruulation .... _J
corrugated or layered paper pipe insulation .... 3 0_ JO insulating annW ..................
spra)-on fireproofing ...................... _/ boweYway rcoatings............. _J
clods woven fabrics . .......... . ....... Oarrsile board, wall board .............
12. Describe the decontamination system(s) to be used:
Chane Room
13. Describe the containerization/disposal methods to compty with 310 CMR 7.15 nd 453, MR 6.14 ?)rrota
All ACM to be doubled bagged in 6 mil labeled aestval bags.
14. For Emergency Asbestos Abatement Operations, the DEP and DLI officials who evaluated the emergency:
Nun rVAR Oawx
nw
AeA plAultrairxan itrwN
Narmolrauauux
TO
&NaAutd aha Wywr/
15. Do prevailing wage rates apply as per M.G.L. c.149, § 26, 27, or 27A - F to this project? 0 Yes 0 No
Rev. 02
Facility Descrlptlon
1. Current or prior use of facility: dey
Residential
2. Is the facility owner -occupied residential with 4 units or less? X7 Yes ❑ No
3. Facility Owner.
SAME
None Address'
_
0170wn low Tilepuiart
4. Facility's Owner's On -Site Manager.
. .. N/A
Name A0109
Cltygown Zo dodo JiVgwano
5. General Contractor:
Name Addross
Gryrrown Zo code TolopAono
Granite State Insurance Company 3518749 11/28/98
Conluclor's Worion Comp. Insuror Polity I l Xp.tkro
6. What is the size of the facility? 2400 (sq n) 2 (1 of floors)
Note: Contractor
must sign this President Asbestos Free, Inc. (781) 245-4403
form for DLI NOW
notification
purposes 42 Broadway. Wakefield, MA Ot ggn
Wea 000" lip code
Fee exempt (City, Town, district, municipal housing authority, owner -occupied residential of four units or less) U3 yes ❑ no
Sticker i (from front of form): 730993
Asbestos Transportation and Disposal
1. Transporter of asbestos -containing waste material from site to temporary storage site (if necessary) to final disposal site:
Asbestos Free, Inc. .42 Broadway
Nome Address
Wakefield, MA 01880 (781) 245-4403
C4ry/Jown 10 code TOO"
2. Transporter of asbestos -containing waste material from removal/ temporary storage site to final disposal site:
'
R66overy Express, Inc. 180 Canal Street
adores
Boston, MA 0211 (ht 7) 523-.7.740
T
Note: Transfer
►i/Town 10 co MOW
Stations must
3. Refuse transfer station and owner (if applicable):
comply with the
Solid Waste
Division regula-
tions 310 OMR
18.00
Qty/Town Ifo code lolepl+orw
4. Final Disposal Site:
Kelly Run Landfill,:Inc. Route #51,.South
loUAcn dlune Owrars Mine
Elitabeth,.PA (800) 886-7282
Address
_
G'ry/rown Ilp � TMep�
The undersigned hereby states, under the penalties of perjury, that he/she has read the Commonwealth of Massachusetts Regulations
for the Removal, Containment or Encapsulation of Asbestos, 453 CMR 6.00 and 310 CMR 7.15, and that the information contained in
this notification is true and correct to the best of his/her knowledge and belief.
Frank L. Arsenault October 12= 1998
Pmt Nanm AuNatlred Siynllura Due
Note: Contractor
must sign this President Asbestos Free, Inc. (781) 245-4403
form for DLI NOW
notification
purposes 42 Broadway. Wakefield, MA Ot ggn
Wea 000" lip code
Fee exempt (City, Town, district, municipal housing authority, owner -occupied residential of four units or less) U3 yes ❑ no
Sticker i (from front of form): 730993
is
42 Broadway • Wakefield, MA 01880
Tel: 781-245-4403 • 800-649-6160 • FAX 781-245-1892
Dear Health Officer,,
Please find enclosed copy of the DEP Notification which is
verification of an Asbestos Removal being performed in
your district.
If you require any further information, or have any questions,
please contact Asbetos Free, Inc. at (781) 245-4403.
Thank you,
/CG��1C
Frank L. Arsenault
FLA/b