HomeMy WebLinkAboutMiscellaneous - 47 HAROLD STREET 4/30/2018 47 HAROLD STREET
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Department of Public Health - Childhood Lead Poisoning Prevention Program
Deleading Notification
Please complete all sections of this form clearly. Incomplete or illegible forms will be returned.
1'
Lead Paint Inspector �ll�V V- License# -�� 1 �9 Inspection Date 11 ► U C
Property Owner GA S�y ��� S�-•l 1 L�r�
Property Owner's Address (pdt 0 d /V1 A Zip Code 0 � � S Z
Authorized person performing work_ 6-e � S,,Ak4 ,�'L, Lic#/Auth.# 0'1q5-6 OA-1
Address of authorized person G q � ,(A k:, Zip Code Q<
Telephone Number�? 5 a
Address where the work will be done:
Building Name (if any)_ H 1A Floor P _
Street Addressq1_tA 1-1o,Ok ,f,\ Ski-- , Apt No.
City/{(, Ar.c�.J ✓ lip Code. (� t Jj The property is a multi-family i single family.
Deleadin2 Method(s):
a Making.paint intact(high risk) o Making paint intact(moderate ❑ Applying vinyl siding on exterior
a Demolition risk) ❑ Component removal (low risk
a Scraping ❑ Liquid encapsulant components)
1�k Component removal/replacement X-- Covering ❑ Other:
a Dipping ❑ Capping baseboards
The work will begin on /W/()land will finish by /�L3 OThe work be done in the V-am fpm or K weekends.
In Case of Einergency Contact
Daytime.Phone Q1 Evening Phone Ti ig q -O cd5�7
The Property Owner must complete and sign the following information:
I certify!that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning
Prevention and Control Regulations, 105 CMR 460.000, will conduct deleading work. I further certify that the authorized
person(s)will not exceed the scope of his/her authority and will be performing only those activities indicated above. All of the
information contained in this document is true and correct to the best of my knowledge and belief.
Date_ Signed `
The following people/agencies must be notified ten days before beginning work:
I- Occupants of the dwelling unit
2. All other occupants of the residential premises, if any work will be done in the common areas
3. Childhood Lead Poisoning Prevention Program, DPH
M WRHO Fax(781) 774-6700
5 Randolph St,Donovan Building
Canton, MA 02021
4, Asbestos and Lead Program, DLWD
399 Washington St., Boston, MA 02108
Fax(617) 727-7568
�- Local Board of Health/Code Enforcement Agency
If the home is on the State Register of Historic Places,call the MA Historical Commission at(617)727-8470.
Air Quality Experts, Inc.
Asbestos Removal
Christopher Thompson 40 Lowell Road, Unit 1 Residential-Commercial-Industrial
(603) 894-6465 Salem, NH 03079 1-800-621-1189
TOWN OF NORTH ANDOVER/_
ROP RD OF HEALTH
October 29, 1998 '
I '% 4 193 ! I
North Andover Health Department - �-
146 Main Street
North Andover, MA 01845
Dear Sir:
Enclosed please find a copy of notification sent to the state for an Asbestos
Abatement Project.
The job will take place on November 10, 1998.
Project: 47 Harold Street
Any questions concerning this matter should be directed to my attention.
Sincerely,
UC 44
Christopher Thompson
President
e8mmfl/Iwea/f//9INassacbuseffs13
MOMS h 18filleffARN MR—AA V-991
1. Facility location:
Nancy Guilmet 47 Harold Street
Name Address
INSTRUCTIONS North Andover,MA 01845 (978)682-9843
1.All sections of this CIOy Town Zp code Telephone
form must be
completed in order to Basement
comply with the What is the worksite location?Bur/ding name, #, wing,17oor,room
Department of
Environmental 2. Is the facility occupied? ® Yes ❑ No
Protection
notification
requirements of 310
CMR 7.15(ten wonPing 3. Asbestos Contractor:
days prior notificatlon
Is required of any Air Quality Experts,Inc. 40 Lowell Road Unit 1 '
abatementproject).
and the Department Name Address
of Labor and
Industries Salem,NH 03079 (603)894-6465
notification City/Town Z/p code Telephone
requirements of 453 AC 000167 Written
CMR 6.12(ten day's
prior notification Is DLI License# Contract Type(Written Or VerbdV
required ofANY
abatementpmject 4. On-Site Project Supervisor/Foreman:
greater than three
linear or square feet).
2.Submit Original Joseph Sharpe AS 30725
Form To: Name DLICermlcation#
Commonwealth of
Massachusetts 5. Project Monitor:
Asbestos Program
P.O.B.120087-0087
NorthEast Environmental AA000153
3.This Form may be Name DLICertihcabron#
used for notifying the
U.S.Environmental
Protection Agency 6. Asbestos Analytical Lab:
Region 1 of asbestos
demolition/renovation SAME
operations subject to
NESHAPS(40 CFR Name DLI Certification,#
Subpart M).
7. Project start date 11/10/1998 end date 11/10/1998 specific work hours(Mon.-Fri.)7am4nm(Sat.-Sun.)
For Official Use Only
8. What type of project is this? demo/ition reoai renovation other(exp/ain)
Notification#
9. Desg a asbestos abatement procedures to be used: glove bag enclosure i/
Receive date contmnment cleanup encapsula[ron disposa/On/y other(explain)
Receiver
10. Is the job being conducted ®indoors ❑outdoors?
Permit Approve/Denied
11. Total amount of each type of Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear ft.) or other
Decision date surfaces(square ft.)40 to be removed,enclosed or encapsulated:
Linear Square feet Linear Square feet
Boilerbleaching,duct,tank surface coatings 40 Mennal,solid core pipe Insulation
CM-gated or layeredp-perpipe insulatlon Insulabng cement
Spray-on pi-yi—frog r-we%splayer cwtings
Cloths,woven fabdc Transite board,wall board
Other(please describe) Other(please desaibe)
12. Describe the decontamination system(s)to be used:
13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g):
Wet removal into 6 mil Poly Asbestos Labeled Bags.
14. For Emergency Asbestos Abatement Operations,the DEP and DLI officials who evaluated the emergency:
Name of DEP ob9ci81 Title
Date ofAuthonzation Waiver#
Name ofDL rOlAnal Title
Date of Autliolfzamon Waiver#
Rev.6/92 15. Do prevailing wage rates apply as per M.G.L.c. 149,§ 26,27,or 27A-F to this project? ❑Yes ®No
v ,
13
favi/ityDesc�iption
1. Current or prior use of facility:
Home
2. Is the facility owner-occupied residential with 4 units or less? ®Yes ❑No
3. Facility Owner:
Nancy'Guilmet 47 Harold Street
Name Address
North Andover,MA 01845 (978)682-9843
Cily/Town Zip code Te%phone
4. Facility's Owner's On-Site Manager:
Name Address
City/Town Zip code Telephone
5. General Contractor:
Name Address
City/Town Zip code Telephone
Contractor's workers Comp.Insurer Po/icy,# Exp.Date
6. What is the size of the facility?2500(sq ft)2(#floors)
LS AsbesldsTiaasoNA71/o//aod0/sposs/
1. Transporter of asbestos-containing waste material from site to temporary storage site(if necessary)to final disposal site?
Air Quality Experts,Inc. 40 Lowell Road,Unit 1
Name Address
Salem,NH 03079 (603)894-6465
00ty17own Zip code Telephone
2. Transporter of asbestos-containing waste materials from removal/temporary storage site to final disposal site:
J. O.B.Rolloff P. O.Box 6037
Name Address
Chelsea,MA 02150 (617)387-1495
Cio/Town Zip code Telephone
Note:Transfer 3. Refuse transfer station and owner(if applicable):
Stations must
comp/y with the Name Address
So/id Waste
Division regula-
tions 310 CMR aolrown Zip code Telephone
18.00
4. Final Disposal Site:
CT Valley Sanitary Waste Disposal
Location Name Owners Name `
161 New Lombard Road
Address
Chicopee,MA 01020 (413)594-4172
CiVrown Zip code Telephone
� Certificatie�
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.
Christopher Thompson CI.�AA A X-1 „Q- 10/28/98
PnntName Authorized Signature Date
Note:Contractor President Air Quality Experts,Inc. (603)894-6465
must sign this Posidonitle Representing Te%phone
form for DLI
notification 40 Lowell Road,Unit 1 Salem,NH 03079
Purposes Address CIO/Town Zip code
Fee exempt(City,Town,district,municipal housing authority,owner-occupied residential of four units or less)?®Yes ❑ No
Sticker#(from front of form): 728619