The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 89 Milk Street (3)i co m m m ao F�f fair Quality Experts, Inc. 3 Brentwood Avenue, Salem, New Hampshire 03079 Asbestos Removal Christopher Thompson NH (603) 894-6465 • MA (617) 734-8700 Residential • Commercial • Industrial "f" ;P,..04W '41 �-, • . UE e Cainruclifinafth of tt5�rc1 ItyEil DEPARTMENT OF LABOR AND INDUSTRIES DIVISION OF -INDUSTRIAL SAFETY NOTIFICATION OF ASBESTOS WOR (In accordance with the provisions of M.C.L. C. 1.49 All sections of this. form must be com Ieted in order 5F and 453 CMRo.12) the notification requirements of 453 CM.�2 612comp2y with TEN DAY PRIOR NOTIFICApIQN IS, REQUIRED OF ANY-ABATci4ENT PRQTECT GREATER THAN THREE (3) LINEAR OR 3QUAP,;' FEET DLI FILE NUMBER Contractor performing project ,q I-rg- EXP License AC 0601 , .7 DO prevailing rates of wages apply to this project as required ore) under M-G.L c. 149, §26, 27 or 27F? (circle ..YES Address of Project Building Marne (if any) //7Q/YCI.( 4n.,__, Street Address* city �/D, i4/y • Zip_ Q /�_ Phone .t'b Project type (circle one): :q DEMOLITION PX PAIR r If 'Other' selected,.please explain Asbestos Activity: (circle one): Ell'CAPSGZATION ASS0CIAT3D PRWECT ENCLOSURE - ' MOv, • , Indicate amount of: asbestos• surface on pipes or ducts OR % LINEAR FEET ., Pipes or ducts to be removed, enclosed orsencapsulatedbestos ce on structures other than D SQUARE FEET Start eate_ an�_ pm weekends? Completion Date_ Project Supervisor Name Certificate # Asbestos Analytical Lab Name e Certificata dGOd�.i Mane 5 Address of disposal sites) � � 0049x/1 i .�s asLcstos contract written or -verbal? r cto- Cc�n`„a 's workers' Con nsation insurer �2.0 y Policy Ncuabe ?acility. Owner ✓ r �/�2 y Address �h _ Cit y �2 State Descr; + `! zip d /�•/� Pt -on. of work practices ' to be followed; Description of decentamirat ion system(s) 14o,to be used � /-� D escription of h?-ndli ... n°/a'isposal rethods to-- compl y with 453 C :4 6.14(2j (gl 'ane and address of transporter(.) if ocher than the asbestos contractor: �e undersigned hereby states 'ad and understood the under. the Penalties Koval, Conta: C°mn:onwealth of Nassachus of perjury, that anent or E,�cs�sul efts Re helshe has "r'Jtion contained ' ation of rsbestoslatior-s for the s1her knowled in this notification 453:C,� 6:;00, and that 9e and belief. is true and correct the to the best of to tL ., _ "Se return this form to: Asbestos Control Technical Services A^nar "nen" of Labor and Division of Industries Industrial Safety t00 Cambridge Street It Poston, HA Room 1101 0?202 ?,112 f • ........................................ ... Telephone 13 Asbestos Removal Description 1. Asbestos Contractor Afw 1A ... 9-W. Z:nLfAer ..................... Address J9..Vz .................................. Add= Rev. 1/91 cityl7own Telephone ___R e- DeAM4l01LWand 1ndUS1fi8$UC1fis;1 Page 1 of 4 Massachusetts Department of Endronmental Protectloj7 !tld]l Bureau of Waste Prevention - Air Quality »••• ......... BWPAQ 04 Asbestos Removal Notification BWP AQ 06 Notification Prior to Construction or Demolition --- -- ----------- - Facility ID (ff known; Permits for Asbestos Permk .... . ..... . ... 13Applicability Received Date ........ . Reviewer Demolition/Renovation operations involving asbestos renovation operations and demolition/renovat!6n io'piraiiion'si: . Permit CAPPr, 0 DWW containing material (ACM) and general Demolition/Renovation Involving ACM is required equired under 310 CMR 7.09 . (2) and 310.' D%ition Date ..... operations are regulated by the Department of Environmental CMR 7.15 (1) (b) twenty (20) days'prior to'any.wo.rkt.elrig.. Protection (DEP), Bureau of Waste Prevention -Air Quality performed. The following information ls*require'*d pursuant to Division, under Regulations 31*0 CMR 7.00, 7.09 and 715. 310 CMR 7.15' Notif !cation to the REGIONAL OFFICE of general demolition/ General Project Description' 1. Facility ................ 3. On -Site Manager jO .... ..............................Hama .............. Address............................. 1Wd......................... . ..................... clV70" Address .................................................... ..............»...»....................»»............. Telephone Cl y/Toa $ize . ..... .. .». ... . ..»..... . ................ . .... . . . . . . ............... Telephone -� ....... . . ................................................ SqLall ket _....».............. . ............. . . . . . ................................................... 4. General Contractor Number of 11ow Name Was the Facility built prior to 1980? t -Yes 0 No Address _»....».».......»........._........................ .. . .................. . . ........... .. . ..... Cumnl or ftr use of Fxxy Cly/Town Is the Facility Occupied? 0 Yes No Is t . his Facility Owner -Occupied Resilential with 4 units or less? 0 -les 0 No Telephone 2. Facility Owner Does this project Involve the removal and/or alteration of .4;901 /_7 ... Aq.,.VA�4............................................ any Asbestos Containing Material (ACM) as defined and applied In 310 CMR 7.00 and 7.157? Kyes 0 No ........................................................ ....... ........................... Addiez If Yes, complete Sections C and D. ........................................................................................................... cily1rom If No, complete Sections D and E. ........................................ ... Telephone 13 Asbestos Removal Description 1. Asbestos Contractor Afw 1A ... 9-W. Z:nLfAer ..................... Address J9..Vz .................................. Add= Rev. 1/91 cityl7own Telephone ___R e- DeAM4l01LWand 1ndUS1fi8$UC1fis;1 Page 1 of 4 Rev. 1/91 Massachusetts Department 01 Environmental'Protection ` Bureau of Waste Prevention —Air Quality'!..L.l...l . . . BWP AQ 04 Asbestos Removal Notification Transmittal / BWP AQ 06 Notification Prior to Construction or Demolition i Permits for Asbestos Facility lD (ilknoiv, 2. On -Site Supervisor 0 Y Z -7 e A"unr o/ tabor and Induslnes Cejj&2don 3. Hygienist ............. 4. Specific Worksite Locations(s) (i.e. Building name, number, wing, floor, room, tunnel.) ..ff .r1.. t; -.Y p- ...:..................:. ........................... 5. Is the job being conducted indoors or outdoors? 6. Estimated amount of Each type of ACM to be handled boiler, breeching, duct, Linear / Square Feet tank surface coatings9. Describe the asbestos removal procedures to be used. ............. �0....... ❑ glove bag ❑ enclosure V<l containment ❑ cleanup ❑ encapsulation ❑ disposal only ........... /I ❑ other -please describe 7. Description of techniques used for estimation 8. Asbestos Removal ..,r':...4.L. SortDate ...... ........................ .................... . EndDaie..y... :.�............ ........................................................... Hours of Operation r% fc — 6 A" gl,daytime ❑ evening ❑ night Days of Operation ZYl01on.— ri. ❑ Sat.—Sun. (Note. Anaarrtg�s in these dates must be reported to the appropriate regional office. If a removal is postponed for more than thirty (30) calendar days separate notification will be required.) thermal, solid core pipe insulation corrugated or layered Paper pipe insulation insulating cement .............. 10. Transporter of asbestos -containing waste material from site to temporary storage site (if necessary) to final disposal site ............................ spray -on fireproofing / .................... trowel/sprayer coatings ............................ cloths, woven fabric / ............................ transhe board, wall board / ............................ other— please describe / ............................ Total in Linear Feet .............. Total in Square Feet ..�.... Nara....................................................................... I ..................................... ................................................................ Address ........... iy/rown .. ................................................... .............. .......................................... Pape 2 of Rev. 1/91 Massachusetts Department of Endronmentai Protection Bureau of Waste Prevention — Air Ouality59-14/l BWP..AQ 04 Asbestos Removal Notification Transinittal� BWP AQ 06 Notification Prior to Construction or Demolition Permits for Asbestos facXty l p (d kno 11. Transporter of asbestos -containing waste material front.: removal/temporary storage site to final disposal site " Na/ne ��,�r��✓ate n %i v� S(reelAddless cl-�___E?L_� Telephone 12. Refuse transfer station facility and owner (if applicable) Nam................................................................... Address................................................................................................ Ciry/ro wn.............................................................................................. _..................................................................................................... Ie/epAone ..... ...................»...»...............». Owner's Name ..................................................... (Note: Transfer Stations must comply with the Solid Waste Division regulations 310 CMR 18.00.) 13. Final Disposal Site ........... .......... ».. 0 . o P....:........ TelepAav�e.-•»..»......._......»».............. C►►ne/SNamy .. (Note Disposal of ACM must corn f DH W9111hi"Solid `Waste Divisions regulations 310 CMR 1.9.00f j) t 14. Emergency Asbestos "Removal DEP officialwho evaluated the emergency:' Na......................................................................»............................. Vie. ................................................. AulAorry_ ».......» ..............................»...»..».....».............................. ..................................... ' General Demolition/Renovation Description 1. Demolition/Renovation Contractor Name Addiess 2. On -Site Supervisor ' Naar............................................................................................. 3. Identify the specific Worksite Location(s): 4. Was the facility surveyed for the presence of asbestos containing material (ACM)? ❑ Yes ❑ No If yes, who Conducted the Survey? Narr�.................................................................»................................. . .............................................................. lkDa�bnenl alada and /nduslnes CeAilialion/ """ S. If yes, who conducted the survey? Name..........»............................................................................... L1eNrbrxnl ala0or »d Indusldes CerfilloA'on / »».".......«..»«»------'-.... 6. Demolition/Renovation Asbestos Removal SbrrOa/e............................. ..Ind Dale................................................. Pape 3 of . .Rev. 1/91 •�.............. Afassachusetis Department of fnvlronmental Protecflon Bureau .. Of Waste Prevention —Air Oualiry �?,l,y..,(.,,..• BWP•AQ 04 Asbestos Removal Notification Tansmittal� BWP AQ 06 Notification Prior to Construction or Demolition L . ......................... Permits for Asbestos Faciiil lD (d knot 7. Describe the demolition/renovation procedures to be used:.. (Note: Demolition/Renovation Operations must comply with 310 CMR 7.09 to control emissions to prevent a condition of air pollution.) 8. Emergency Demolition/Renovatlon Asbestos Removal Operations State or local official who evaluated the.emergency:. Ahnr TNk AUMnly . aav aAWhairarion -- (General Statement: If asbestos -containing material is unexpectedly found or damaged during a DemolitioNRenovation 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 releaseAhreat 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). ............ , �uCroviteaSlpnafum....... ................................. l./j��5 .� r PhObvive.............................. Representing ................. Qalc:..�r .-.. .1 ...................................................... Pace 4 of c