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Home My WebLink About- Miscellaneous - 26 HERRICK ROAD 11/13/2018 Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) Asbestos Assbestt Project# Asbestos Notification Form r Project Revision r Project Cancellation A. Asbestos Abatement Description 1,Facility Location: PENNEY 26 HERRICK ROAD ttk Instructions 1.All a.Name of Facility b.Street Address sections of this form NORTH ANDOVER MA 01845 0000000000 must be completed in order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification x x requirements of 310 CMR 7.15 and g•Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksite Location: BASEMENT Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc. requirements of453 2, Is the facility occupied? W a.Yes r b.No CMR 6.12 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner-occupied residential property of four units or less)? W a.Yes r— b.No MassDEP Use Only 4.Blanket Permit Project Approval,if applicable: Date Received Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: Approval ID# G.Asbestos Contractor: NEW ENGLAND SURFACE MAINTENANCE LLP 850 WASHINGTON ST a.Name b.Address We-MOUTH MA 02189 7813372117 c,City/Town d.State e.Zip Code f.Telephone AC000196 h. Contract Type: ry I. Written r 2.Verbal g.DLS License# 7 JOSE VtLLALTA AS061825 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# RtCHARD K.BOWEN AM061044 a.Name of Project Monitor b.DLS Certification# 9. FLI ENVIRONMENTAL INC AA0�00144 a.Name of Asbestos Analytical Lab b.DLS Certification# la. 11/19/2018 11/19/2018 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 8-4 N/A c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11. What type of project is this? r a.Demolition r b.Renovation W c.Repair r d.Other-Please Specify: Revised: l 1/13/201'3 Page I of 4 Massachusetts Department of Environmental Protection 100297536 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification For r Project Revision r Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): r a.Glove Bag r b.Encapsulation r c, Enclosure r d, Disposal Only r C.Cleanup ry f. Full Containment r g, Other-Please Specify: 13.Job is being conducted: rV a. Indoors r b.Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 100 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct, c,Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation 100 c.Transite Shingles 1.Lin.Ft. 2.Sq.Ft. TALinFt. 2.Sq.Ft. f. Spray-On Fireproofing g.Transite Panels 1.Lin,Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h.Cloths,Woven Fabrics i. Other-Please Specify: 1.Lin.Ft. 2.Sq,Ft. j.Insulating Cement T Lin Ft 7E Sq.Ft. 1,Lin.Ft. 2.Sq.Ft, 15,Describe the decontamination system(s)to be used: AS REQUIRED 16.Describe the containerization/disposal methods to comply with 310 CN4R 7,15 and 453 CMR 6.14(2) (g): AS REQUIRED 17, For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MMIDDNYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# M Do prevailing wage rates as per M.G.L. c. 149, §26,27 or 27A-T apply to this r a.Yes rV b,No project'? Revised: 11/13/2013 Page 2 of 4 Massachusetts Department of Environmental Protection 100297536 I—-.. ......... : ..__'--, ] BWP AQ 04 (ANF-001) Asbestos Project 9 Asbestos Notification Form r Project Revision r Illrglect Cancellation ........... B. Facility Description 1.Current or prior use of facility: RESIDENCE 2. Is the facility owner-occupied residential with 4 units or less? ry a,Yes r b.No 3, PENNEY 26 HERRICK ROAD a.Facility Owner Name b.Address NORTH ANDOVER MA 01845 0000000000 c.City/Town d.State e.Zip Code f.Telephone 4.X X a.Name of Facility Owner's On-Site Manager b.Address X MA 00000 0000000000 c.City/Town 7,State_W zip-code f.Telephone 5.X X a.Name of General Contractor b.Address X MA 00000 0000000000 c,City/Town d.State e.Zip Code f.Telephone X g.Contractor's Worker's Compensation Insurer X 1/1/2019 h.Policy# i.Expiration Date(MM/DDNYYY) 1400 2 6.What is the size of this facility? a.Square Feet b,#of Floors Note:Temporary storage of Asbestos C. Asbestos Transportation & Disposal containing waste 1,Transporter of asbestos-containing waste material from site of generation: material is only allowed at the place r a.Directly to Landfill or r-/ b.,i,o,reiiiporai,ySt(.)rage location/Transfer Station of business of a DLS licensed Asbestos contractor or a transfer NEW ENGLAND SURFACE MAINTENANCE,LLP 850 WASHINGTON STREET station that is c.Name of Transporter d.Address permitted by MassDEP and WEYMOUTH MA 02189 7813372117 operated in e.City/Town f.State g.Zip Code h.Telephone compliance with Solid Waste Regulations 310 OMR 19.000 2. If a temporary storage location/transfer station is used,list name of transporter of asbestos containing waste material from temporary storage location/transfer station to final disposal site: RED TECHNOLOGIES 10 NORTHWOOD DRIVE a.Name of Transporter b.Address BLOOMFIELD CT 6002 8602182428 c.City/Town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 Massachusetts Department of Environmental Protection 100297536 BWP AQ 04 (ANF-001) Asbestos Project Asbestos Notification Form r Project Revision r Project Cancellation C.Asbestos Transportation& Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: RED TECHOLOGIES 203 PICKERING STREET a.Temporary Storage Location Name b,Address PORTLAND CT 06480 8603421022 c.Cityfrown d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA ENTERPRISES MINERVA a.Final Disposal Site Name b.Final Disposal Site Owner Name 9000 MINERVA ROAD c.Address WAYNESBURG OH 44688 3308663435 d.Dty/Town e.State f.Zip Code g,Telephone Note:Contractor must sign this form for DLS notification purposes D. Certification JIM DOYLE JIM DOYLE "I certify that I have personally 1.Narne 2.Authorized Signature examined the foregoing and am PARTNER 11/5/2018 familiar with the information - 3.Position/Tige 4,Date(MM/DDNYYY) contained in this document and all attachments and that, based 7813372117 NESM,LLP on my inquiry of those 5.Telephone 6.Representing individuals immediately 850 WASHINGTON STREET WEYMOUTH responsible for obtaining the 7.Address 8.City/Town information,I believe that the MA 02189 information is true, accurate,and 9.State 10.Zip Code complete. I am aware that there are significant penalties for submitting false information, including possible fines and imprisonment.The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 4 of 4