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Home My WebLink AboutMiscellaneous - Exception (28)2 DECTAM 50 CONCORD STREET, NORTH READING, MASSACHUSETTS 01864 August 25, 2004 Health Department Town of North Andover 27 Charles Street North Andover, MA 01845 RE: Asbestos Abatem t-38 Columbia Road Dear Sir or Madam: .TOWN TH pEPF.RIMEN 978-470-2860 FAX 978-470-1017 Please be advised that Dec -Tam Corporation will be performing an asbestos abatement project at the above referenced location. This work is scheduled for September 7, 2004 through September 8, 2004. All applicable local, state and federal agencies have been notified of this work. Please let me know if you have any questions. Sincerest regards, �od Lee Snodgrss President LS/jmp Enclosure ASBESTOS ABATEMENT A MOLD REMEDIATION www.dectam.com E-mail: solutions@dectam.com A LEAD ABATEMENT Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. reran INSTRUCTIONS 1. All sections of this form must be completed in order to comply with DEP notification requirements of 310 CMR 7.15 and the Division of Occupational Safety (DOS) notification requirements of 453 CMR 6.12 Commonwealth of Massachusetts Asbestos Notification Form ANF -001 RECEIVED A. Asbestos Abatement Descr 776839 Please Enter Decal # 776839 on eft-oV .� TOWN OF NORTH ANDOVER Facility Location: HEALTH DEPARTMENT Ms Fatima Delgado 38 Columbia Rd Name of Facility Street Address North Andover Ma 01845 Cityrrown State Zip Code Worksite Location: Residence Building name, #, wing, floor, room. 2. Is the facility occupied? ® Yes ❑ No 3. Asbestos Contractor: Telephone Dec -Tam Corporation 50 Concord St Name Address N. Reading. MA 01864 978470-2860 Citylrown Zip Code Telephone A0000035 DOS License # Contract Type: ® Written ❑ Verbal Brian P. Fitzsimons VP Facility Contact Person Contact person's title Charles Brewer ASB30534 4 Name of On -Site Supervisor/Foreman DOS Certification # Covino 5' AA000006 Name of Project Monitor DOS Certification # 6 Covino AA000006 Name of Asbestos Analytical Lab DOS Certification # 2. Submit Original Form to: <7Ah Commonwealth of 9/7/04 Massachusetts 7• Asbestos Program project Start Date End Date PO Box 120087 Boston MA 02112-0087 730A -430P N/A Work hours Mon -Fri. Work hours Sat -Sun. 8. What type of project is this? ❑ Demolition ® Renovation ❑ Repair ❑ Other, please specify: 9. Check abatement procedures: ® Glove bag ❑ Encapsulation ❑ Enclosure ❑ Disposal only ❑ Cleanup ❑ Other, specify: ❑ Full containment 10. Is the job being conducted: E Indoors? ❑ Outdoors? Blank Notification • 9/02 01_0ul k4 a -i4 Asbestos Notification Form • Page 1 of 4 i � Commonwealth of (Massachusetts . Asbestos Notification Form ANF -001 776839 Please Enter Decal # A. Asbestos Abatement Description (cont.) 11. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or encapsulated: pipes or ducts (linear ft) other surfaces (square ft) Boiler, breaching, duct, tank surface 35sf / / coatings lin. ft sq. ft Insulating cement lin. ft sq. ft Corrugated or layered paper pipe 1001f / / insulation lin. ft sq. ft Trowel/Sprayer coatings lin. ft sq. ft Spray -on fireproofing lin. ft sq. ft Transite board, wall board lin. ft sq. ft Cloths, woven fabrics lin. ft sq. ft Other, please specify: Thermal, solid core pipe insulation fin ft cn ft fin ft en ft 12. Describe the decontamination system(s) to be used: Three Staae 13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): Material will be wetted and placed in double bass and labeled for transporatation 14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: Name of DEP official Date of Authorization Name of DOS official Title Waiver # Title Date of Authorization Waiver # 15. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? ❑ Yes KNo B. Facility Description 1. Current or prior use of facility: Residence 2. Is the facility owner -occupied residential with 4 units or less? XYes ❑ No 3 Fatima Delgado 38 Columbia Rd Facility Owner Name Address North Andover Ma 617 434 5285 City/Town Zip Code Telephone 4. Name of Facility Owner's On -Site Manager CityfTown Address Zip Code Telephone Blank Notification - 9/02 Asbestos Notification Form - Page 2 of 4 ` Y Commonwealth of Massachusetts Asbestos Notification Form 776839 Please Enter Decal # ANF -001 13. Facility Description (cont.) 5. Name of General Contractor Address City/Town Zip Code Telephone AIG WC9694.329 12/28/04 Contractor's Worker's Comp. Insurer Policy# Exp. Date 6. What is the size of this facility? 1700 2 Square Feet # of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos -containing material from site to temporary storage site (if necessary) to final disposal site: Service Transportation Group 58 Pyles Lane Note: Transfer Name of transporter Address Stations must New Castle, DE 19720 302-778-5930 comply with the Solid Waste City/Town Zip Code Telephone Division 2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 As Above Name of transporter Address City/Town Zip Code Telephone 3. Refuse transfer station and owner Address Cityrrown Zip Code Telephone 4. Minerva Landfill n/a Final Disposal Site location name Owner's Name 9000 Minerva Road Waynesburg Address City/Town OH 44688 330-866-3435 State Zip Code Telephone D. Certification The undersigned hereby states, under the penalties of perjury, that he/she has read the Commonwealth of Massachusetts Note: Contractor regulations for the Removal, Containment must sign this form or Encapsulation of Asbestos, 453 CMR for DOS notification 6.00 and 310 CMR 7.15, and that the purposes information contained in this notification is true and correct to the best of his/her knowledge and belief. Lee Snodgrass Name Pres Position/Title 978-470-2860 Telephone N. Reading,MA City/Town Authorized Signature a Date Dec -Tam Representing 50 Concord St Address 01864 Zip Code Fee exempt (city, Town, district, municipal housing authority, owner -occupied residential of four units or less?) ❑ Yes ❑ No Blank Notification - 9/02 Asbestos Notification Form - Page 3 of 4 eDEP: Print Receipt Submittal Summary & Receipt Your submission is complete. Thank you for using DEP's online reporting system. You can select "My Homepage" to review your status. DEP Transaction ID: 14936 Date and Time Submitted: 8/25/2004 11:29:47 AM Form Name: ANF -001 and AQ 06 Project Date Revision Notification DECAL # and Facility information Form Name: ANF001 DECAL #: 776839 Facility Name: MS FATIMA DELGADO Address: 38 COLUMBIA RD, NORTH ANDOVER, MA Original Project Dates Start Date: 9/7/2004 - End Date: 9/10/2004 Revised Project Dates Start Date - End Date ��Print Cancel. Page 1 of 1 https://edep.dep.mass, gov/Restricted/webpages/printreceipt.aspx 8/25/2004