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DECORPORATION
Specialty Contractors
December 26, 2012
North Andover Board of Health
1600 Osgood Street, Bldg 20, Suite 2-36
North Andover, MA 01845
RE-Rradslre._etSchool, 70 Main Street, -North Andover, MA 01845
(Connector to Modular)
Dear Sir or Madam-
978.470.2860
fax 978.470.1017
REDEME-D
rl.-� n r"
ESL.'. LOIZ
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Please be advised that Dec -Tam Corporation will be performing an asbestos abatement
projects at the above referenced locations. This work had been scheduled for
January 04, 2012 thru January 04, 2012
All applicable local, state and federal agencies have been notified of this work.
Please let me know if you have any questions.
Sincerest regards,
Brenton Morgenstern
Sales Estimator
BMJcam
Enclosure
Environmental Remediation Services - Surface Preparation - Facilities Services
50 Concord Street - North Reading, MA 01864 - www.dectam.com - solutions@dectam.com
4.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealtti`of Massachusetts
l \
Asbestos Notification Form ANF -001
A. Asbestos Abatement Description
100168217
Decal Number
1. a. Is this facility fee exempt - cit , town, district, municipal housing authority, owner -occupied
residence of four units or less? j✓ Yes ® No
b. Provide blanket decal number if applicable- Blanket Decal Number
2. Facility Location:
INSTRUCTIONS 3'
1. All sections of this
form. must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR 7.15 5.
and the Division
of Occupational
Safety (DOS)
notification
requirements of 453
CMR 6.12
(BRADSTREET SCHOOL 170 MAIN STREET.
a. Name of Facility b. Street Address _
NORTH ANDOVER MA 19787941503
c. City/Town d. State e. Zip Code f. Telephone Number
Worksite Location:
CONNECTOR TO MODULA
a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room
Is the facility occupied? 0 Yes 2] No
Asbestos Contractor:
DEC -TAM CORPORATION 50 CONCORD STREET
a. Name b. Address
NORTH READING 19784702860
c. City/Town d. Zip Code e. Telephone Number
(BRENT MORGENSTERN
GEORGE A. PAGE
6' a. Name of On -Site Sup
RPF
7' a. Name of Project Monit
RPF
$' a. Name of Asbestos Ani
9 11/4/2013
a. Project Start Date (m
7A -4P --
c. Work hours Mon -Fri.
10. a. What type of project is this?
El Demolition ❑✓ Renovation
❑ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
❑ Glove bag
Enclosure
Cleanup
El Full containment
❑ Encapsulation
El Disposal only
M Other, specify:
g. Contract Type: ❑ Written ❑ Verbal
1 11
d. Work hours Sat -Sun.
ktt5 �_ J V L U
T-7, 31 CU1Z
b. Describe
TOWN OF NORTH ANDOVER
fiEALTH DEPARTMENT
CRIT/NEGAIR
b. Describe
12. Is the job being conducted: []✓ Indoors? ❑ Outdoors?
anf001 ap.doc - 10/02 Id '6 0_07 �
Asbestos Notification Form - Page 1 of 3
Commonwealth of Massachusetts
i Asbestos Notification Form ANF -001
A. Asbestos Abatement Description (cont.)
100168217 !�
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encs sulated:
20 250
a. Total pipes or ducts (linear ) T. TofaTo'fher suRaces squame
c. Boiler, breaching, duct, tank
surface coatings
Lin. ft.
e. Corrugated or layered paper
Sq. ft.
pipe insulation
Lin. ft.
Fft
f. Trowel/Sprayer coatings
g. Spray -on fireproofing
Lin. ft.
h. Transite board, wall board
C�
i. Cloths, woven fabrics
LinL�k.
Lin. .
Thermal, solid core pipe
20
insulation
Lin. ft.
I. Specify
14. Describe the decontamination system(s) to be used:
THREE STAGE
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (a):
MATERIALS WILL BE WETTED AND PLACED IN DOUBLE BAGS AND LABELED FOR TRANSP I
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a. Name EP Offs ial
b. Title
c. Date (mmldd/ ) of Authorization d. DEP Waiver #
e. Name of DOS Official f. 009 OfficialTitle
g. Date (mm/dd/yyyy) of Authorization h. DOS Waiver #
17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? [✓] Yes E] No
B. Facility Description
1. Current or prior use of facility: ACADEMIC
2. Is the facility owner -occupied residential with 4 units or less? ❑ Yes ❑✓ No
TOWN OF NORTH ANDOVER r 1600 OSGOOD STREET, SUITE 3-59
3' a. Facility Owner Name b. Address
NORTH ANDOVER 01845 978-794-1503
c. Ci /Town d. Zi Code e. Telephone Number area code and extension
4' SA
STEPHEN FOSTER ME AS ABOVE
a. Name of Facili Owner's On -Site Manager b. On -Site Manaaer Address
anf001ap.doc • 10/02
C.
d. Zip Code e.
(area
Asbestos Notification Form • Page 2 of 3 —
d. Insulating cement
LinLin�.
Sq. ft.
Fft
f. Trowel/Sprayer coatings
Lin.
q. ft.
h. Transite board, wall board
��ft. _�`j
�_qft.
Lin. .
20
250
j. Other, please specify:
Lin. ft.
BSc . R
ROOF/FLASH
I. Specify
14. Describe the decontamination system(s) to be used:
THREE STAGE
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (a):
MATERIALS WILL BE WETTED AND PLACED IN DOUBLE BAGS AND LABELED FOR TRANSP I
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a. Name EP Offs ial
b. Title
c. Date (mmldd/ ) of Authorization d. DEP Waiver #
e. Name of DOS Official f. 009 OfficialTitle
g. Date (mm/dd/yyyy) of Authorization h. DOS Waiver #
17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? [✓] Yes E] No
B. Facility Description
1. Current or prior use of facility: ACADEMIC
2. Is the facility owner -occupied residential with 4 units or less? ❑ Yes ❑✓ No
TOWN OF NORTH ANDOVER r 1600 OSGOOD STREET, SUITE 3-59
3' a. Facility Owner Name b. Address
NORTH ANDOVER 01845 978-794-1503
c. Ci /Town d. Zi Code e. Telephone Number area code and extension
4' SA
STEPHEN FOSTER ME AS ABOVE
a. Name of Facili Owner's On -Site Manager b. On -Site Manaaer Address
anf001ap.doc • 10/02
C.
d. Zip Code e.
(area
Asbestos Notification Form • Page 2 of 3 —
F
J
Commonwealth of Massachusetts
100168217
Asbestos Notification Form ANF -001 Decal Number
4. IMINERVA ENTERPRISES INC
a. Final Disposal Site Location Name
19000 MINERVA ROAD
c. Final Disposal Site Address
OH 44688
e. State f. Zip Code
D. Certification
1 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.
anf001ap.doc • 10/02
b. Final Disposal Site Location Owner's Name
WAYNESBURG
d. Citvfrown
g. Telephone Number
BRENT MORGENSTERN Brent Morgenstern
a. Name
SALES
c. Position/Title
9784702860
e. Telephone Number _
50 CONCORD STREET
Q. Address
NORTH READING�I
h. City/Town
112/19/2012 1
iDEC-TAM E
01864
i. Zip Code
Asbestos Notification Form • Page 3 of 3
B. Facility Description (cont.)
5'
aa.. Name of General Contractor
b. Address
c. Ci /Town d. Zip Code
e. Telephone Number area code and extension
GREAT DIVIDE INS. CO
WCA153726610 12/28/2012
f. Contractor's Worker's Comp. Insurer
9. Policy Number h. Exp Date(mm/dd
60000 �4
6. What is the size of this facility?
a. Square Feet b. Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site
to temporary storage site (if necessary):
Note: Transfera.
Name of Transporter�
b. Address
Stations must
�
comply with the
c. Cityfrown d. Zip Code
e. Telephone Number
Solid Waste
Division
2. Transporter of asbestos -containing waste material
from removal/temporary site to final disposal site:
Regulations 310
CMR 19.000
SERVICE TRANSPORT
58 PYLES LANE
a. Name of Transporter
b. Address
_
NEW CASTLE, DE �� 19720
8 '79999559
c. Ci /Town d. Zip Code
e. Telephone Number
a. Refuse Transfer Station and Owner
b. Address
4. IMINERVA ENTERPRISES INC
a. Final Disposal Site Location Name
19000 MINERVA ROAD
c. Final Disposal Site Address
OH 44688
e. State f. Zip Code
D. Certification
1 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.
anf001ap.doc • 10/02
b. Final Disposal Site Location Owner's Name
WAYNESBURG
d. Citvfrown
g. Telephone Number
BRENT MORGENSTERN Brent Morgenstern
a. Name
SALES
c. Position/Title
9784702860
e. Telephone Number _
50 CONCORD STREET
Q. Address
NORTH READING�I
h. City/Town
112/19/2012 1
iDEC-TAM E
01864
i. Zip Code
Asbestos Notification Form • Page 3 of 3
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