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(603)894-6465
(800) 621-1189
'(603) 894-7044 FAX
Air Quality Experts, Inc --
September 15, 2003
Asbestos Removal
40 Lowell Road, Unit 1 Residential -Commercial -Industrial
Salem, NH 03079 AirQualityExperts@AQENH.com
North Andover Health Department
146 Main Street
North Andover, MA 01845
Dear Sir:
tA
SAF Z ti
IL
Enclosed please find a copy of notification sent to the state for an Asbestos
Abatement Project.
The job will take place on September 29, 2003.
Project: 20 Hodges Street
Any questions concerning this matter should be directed to my attention.
Sincerely,
C1�1 a ---
Christopher Thompson
President
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
INSTRUCTIONS
Commonwealth of Massachusetts ■
100001001
Asbestos Notification Form ANF -001 Decal Number
Affix Asbestos
Notification Decal
Here
---------------------------------------
A. Asbestos Abatement Description
a. Is this facility fee exempt - city, town, district, municipal housing authority, owner -occupied
residence of four units or less? M Yes ❑ No
b. Provide blanket decal number if applicable:
2. Facility Location:
FRED SPICER
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
N
a. Name of Facility
NORTH ANDOVER MA
c. City/Town d. State
❑_
Blanket Decal Number
20 HODGES STREET
b. Street Address
01845 _ ❑❑______._...,_._.___._..___"_..._."." �❑
e. Zip Code f. Telephone Number
Worksite Location:
BASEMENT E= ❑= L= � ❑
a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room
Is the facility occupied? ❑✓ Yes ❑ No
Asbestos Contractor:
AIR QUALITY EXPERTS, INC.
I
a. Name
SALEM
c. Cit /Town
d. Zip Code
AC000167
f. DOS License Number
h. Facility Contact Person
GERMAN POSADA ZINIGA
a. Name of On -Site Supervisor/Foreman
NA
7' a. Name of Project Monitor
8 NA
a. Name of Asbestos Analytical Lab
9. 09/29/2063
a. Project Start Date mm/dd/
7AM-1 PM
c. Work hours Mon -Fri.
10. a. What type of project is this?
El Demolition 9 Renovation
❑ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
❑✓ Glove bag
❑ Enclosure
❑ Cleanup
❑ Full containment
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
40 LOWELL ROAD, UNIT 1
b. Address
6038946465
e. Telephone Number
g. Contract Type:❑✓ Written ❑ Verbal
b. Describe
b. Describe
12. Is the job being conducted: ❑✓ Indoors? ❑ Outdoors?
0 anf001 ap.doc • 10/02 Asbestos Notification Form - Page 1 of 3 0
M1.f
l . Commonwealth of Massachusetts ■
� 100001001
Asbestos Notification Form ANF -001 Decal Number
A. Asbestos Abatement Description (cont.)
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed,
or
enggapsulated:
c. Date (mm/dd/yy)y) of Authorization
d. DEP Waiver #
50
f. DOS Official Title
g. Date (mm/dd/yyyy) of Authorization
a. Total pipes or ducts (linear ft)
b. Totalof er su aces square t
c. Boiler, breaching, duct, tank
d. Insulating cement
B. Facility Description
surface coatings
Lin. ft. Sq. ft.
Lin. ft.
Sq. ft.
e. Corrugated or layered paper
50
f. Trowel/Sprayer coatings
0
pipe insulation
Lin. ft. Sq. ft.
Lin. ft.
Sq. ft.
g. Spray -on fireproofingLif
h. Transite board, wall board
b. Address
F—
q.
Lin.
q. ft -
d Zip Code ee. Telephone Num— area code and extension _._.........,
LL
4.
a. Name of Facility Owner's On -Site Manager b. On -Site Manager Address
z
i. Cloths, woven fabrics
j. Other, please specify:
i� S
Lin. ftp
SQ. ft.
k. Thermal, solid core pipe
q �ft
Asbestos Notification Form • Page 2 of 3 ■
insulation
Lin. ft. Sq. ft. 1. Specify
14. Describe the decontamination system(s) to be used:
3 CHAMBER DECON
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
WET 2 PLY POLY BAGS
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a. Name of DEP Official
b. Title
c. Date (mm/dd/yy)y) of Authorization
d. DEP Waiver #
e. Name of DOS Official
f. DOS Official Title
g. Date (mm/dd/yyyy) of Authorization
h. DOS Waiver #
N
0
17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? ❑ Yes C✓] No
B. Facility Description
N
RESIDENTIAL
0
1. Current or prior use of facility:
0
2. Is the facility owner -occupied residential with 4 units or less? [✓ Yes ❑ No
FRED SPICER
3' a. Facility Owner Name
b. Address
((
o
c. Cit /Town
d Zip Code ee. Telephone Num— area code and extension _._.........,
LL
4.
a. Name of Facility Owner's On -Site Manager b. On -Site Manager Address
z
E=
Q
c. City/Town
d. Zip Code e. Telephone Number (area code and extension)
■ anf001ap.doc • 10/02
Asbestos Notification Form • Page 2 of 3 ■
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
M
O
0
N
0
0
0
LL
Z
Q
Commonwealth of Massachusetts
Asbestos Notification Form ANF -001
B. Facility Description (cont.)
5. a. Name of General Contractor
jf
__.. _ ......., mm ?777
c..qiY/Town d. ZiD Code
f. Contractor's Worker's Comp. Insurer
6. What is the size of this facility?
100001001
Decal Number
b. Address
e. Telephone Number area code and extension)
g. Policy Number h. Ex Date mm/dd/y
2400 12 5 J
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):
SAME AS CONTRACTOR
a. Name of Transporter
c. City/Town d. Zip Code
b Address
e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
SERVICE TRANSPORT GROUP
b. Authorized Signature
a. Name of Transporter
BRISTOL, PA
C. Ci /Town
119007
d. An Code
3.
d. Date mm/dd/yy
a. Refuse Transfer Station and Owner
C. Ci /Town
d. Zio Code
4. BFI IMPERIAL LANDFILL
f. Representinq
a. Final Disposal Site Location Name
PO BOX 47-11 BOGGS ROAD
03079 v
c. Final Disposal Site Address
IPA�
e. State
15126
f. Zip Code
D. Certification
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.
PO BOX 2132
b. Address
(877) 999-9559
e. Telephone Number
b. Address
E.....e......
e. Tele hone Number
BFI IMPERIAL LANDFILL
b. Final Disposal Site Location Owner's Name
IMPERIAL
d. Cit /Town
(724) 695-0900
g. Telephone Number
CHRISTOPHER THOMPS
a. Name
b. Authorized Signature
PRESIDENT �mmmm�
09/15/2003
c. Positionlritle
d. Date mm/dd/yy
(603) 894-6465�
AIR QUALITY EXPERTS,
e. Telephone Number
f. Representinq
400 L0 ELL ROAD, UNIT ONE
. Address
SALEM, NH�����
03079 v
h. City/Town
i. Zip Code
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E anf001ap.doc - 10/02 Asbestos Notification Form - Page 3 of 3 0