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Home My WebLink About- Miscellaneous - 33 HAROLD STREET 11/28/2018 Massachusetts Department of Environmental Protection [1.0.0.2.9.7.9.9.0 BWP AQ 04 (ANF-001) Asbestos Project# w� Asbestos Notification Form I'""` Project Revision r", Project Cancellation A. Asbestos Abatement Description 1. Facility Location: MATT GOSSELIN 33 HAROLD ST Instructions 1.All a.Name of Facility b.Street Address sections of this form NORTH ANDOVER must be completed in MA 01845 7813152355 order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification MATT GOSSELIN OWNER requirements of 310 CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksite Location: ATTIC Standards(DLS) i.Building Name,Wing,Floor,Room,etc. notification requirements of453 2. Is the facility Occupied? I a.Yes I 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 Tess)? II'r a.Yes II""" 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# 6.Asbestos Contractor: AIR SAFE INC 22 WILLOW STREET a.Name b.Address CHELSEA MA 02150 9783395361 c.City/Town d.State e.Zip Code f.Telephone AC000464 h.Contract Type: l 1.Written I""2 Verbal g.DLS License# 7 ELVYN ALAMO AS901331 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8. KEVIN CLIFFORD AM000092 a.Name of Project Monitor b.DLS Certification# 9 FLI ENVIRONMENTAL INC AA000144 a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 11/21/2018 11/24/2018 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 7AM-5PM 7 AM-5 PM c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11.What type of project is this? r"° a.Demolition r b.Renovation r"""" c.Repair r"° d.Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r,,, Project Revision r", Project Cancellation A.Asbestos Abatement Description: (coat.) 12.Abatement procedures(check all that apply): r' a.Glove Bag r' b.Encapsulation c.Enclosure d.Disposal Only e.Cleanup I f.Full Containment r", g Other-Please Specify: 13. Job is being conducted: Vim` a. Indoors �(.- b. Outdoors 14 a. Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 1000 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 e.Transite Shingles 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 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 VERMICULITE 1000 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15. Describe the decontamination system(s)to be used: THREE CHAMBER DECON 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): 6 MIL POLY 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(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18.Do prevailing wage rates as per M.G.L. c. 149, § 26,27 or 27A—F apply to this r," a.Yes V'+` b.No proj ect? Revised: 11/13/2013 Page 2 of 4 Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r,,, Project Revision r", Project Cancellation B. Facility Description 1. Current or prior use of facility: RESIDENTIAL 2. Is the facility owner-occupied residential with 4 units or less? a.Yes b.No 3 MATT GOSSELIN 33 HAROLD ST a.Facility Owner Name b.Address NORTH ANDOVER MA 01845 7813152355 c.City/Town d.State e.Zip Code f.Telephone 4 MATT GOSSELIN 33 HAROLD ST a.Name of Facility Owner's On-Site Manager b.Address NORTH ANDOVER MA 01845 7813152355 c.City/Town d.State e.Zip Code f.Telephone S N/A N/A a.Name of General Contractor b.Address N/A MA 01845 1111111111 c.City/Town d.State e.Zip Code f.Telephone N/A g.Contractor's Worker's Compensation Insurer N/A 12/31/2018 h.Policy# i.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 1,414 2 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 V""°'" a. Directly to Landfill or V'~ b. To Temporary Storage Location/Transfer Station of business of a DLS licensed Asbestos contractor or a transfer AIR SAFE INC 22 WILLOW ST station that is c.Name of Transporter d.Address permitted by MassDEP and CHELSEA MA 02150 9783395361 operated in e.City/Town f.State g.Zip Code h.Telephone compliance with Solid Waste Regulations 310 CMR 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: SERVICE TRANS GROUP 301 OXFORD VALLEY RD SUITE 803B a.Name of Transporter b.Address YARDLEY PA 19067 8779999559 c.City/Town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r- Project Revision r- Project Cancellation C.Asbestos Transportation&Disposal: (coot.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: AIR SAFE INC 22 WILLOW ST a.Temporary Storage Location Name b.Address CHELSEA MA 02150 9783395361 c.City/Town d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA LANDFILL MINERVA ENTERPRISES,INC a.Final Disposal Site Name b.Final Disposal Site Owner Name 8995 MINERVA DRIVE c.Address WAYNESBURG OH 44688 3308663435 d.City/Town e.State f.Zip Code g.Telephone Note:Contractor must sign this form for DLS notification purposes D. Certification DFW DFW "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PRESIDENT 11/9/2018 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) all attachments and that, based 9783395361 AIR SAFE INC on my inquiry of those 5.Telephone 6.Representing individuals immediately 22 WYCHWOOD DR LITTLETON responsible for obtaining the 7.Address 8.City/Town information, I believe that the MA 01460 information is true, accurate,and complete. I am aware that there 9.State 10.Zip Code 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