HomeMy WebLinkAbout- Miscellaneous - 73 BRADSTREET ROAD 5/28/2019 ,x
Massachusetts Department of Environmental Protection
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BWP AV4--'- 04 (ANF-001)
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Asbestos Notification Form
r Pi.- *ecit Revision
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Project Cancellation
A.
Asbestos Abatement Description
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P T I GL"N I I F ST D T R `
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Instructions 1.All a.Name of Facility b.Street Address
sections f this farm NORTH ANDOVER, MIA 018454
must be completed in
order to comply with G.City/Town d.State e.Zip Conde f.Telephone
MassDEP notification PATRICIA GLYNN OMER
r quir r nernt f 310
.,Facility o nt t Person Name h.Facility Contact Prson Title
CMR'7.15,and
Department f Labor Work it Location: BASEMENT&CRAWLSPACE
Standards(DLS D
rn titi ti rn i.Building Name,Wing,Floor,Room,etc.
requirements of 453 2. Is the illt occupied?M
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 F' bw N
MassDEP Use Only
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4.
Blanket ' rmit Project Approval,ifapplicable:
Late lid Approval ICE
.Non-Traditional Asbestos Abatenient Work Practice Approval,
if a
pll :bl � Appr + l 14
6.Asbestos Contractor:
AIR SAFE INC 22,WILLOW STREET
.Name b.Address
w City/Town d.State + .Zip Code f.Telephone
aRLSLicense
7.
.Rums of rntr n tor"s On,-Site Supervisor/Foreman b.I LS Certification
I F IN CLIF'FORD AM000092
8.
.Name of Project t Monitor b.I LS Cer4ification
FLIENVIRONMENTAL INC AAOOO 144
.Name of Asbestos Analytical Lab b.f LS Certification
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10.
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.Project Start Date /y, b.End Cate MM/DDT),
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.Work Hour Monday'Through Friday d.Work Hours,-Saturday&Sunday
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11.What type of project is this?
f" a.Demolition W b.Renovation r, - c,.Repair I' d.Cither-Pleas,e Specify:
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Revised, 11/13/2013 Page 1 of 4
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Massachusetts Department ofEnwironmental Protection _.
--` 04 (ANF-001)
100308180
BW,P Ad
Asbestos i
, wy.... Asbestos Notification Form
Project Cariceflation
A.Asbestos Abatement Description: (court.)
12. Abatement procedures 1i .1 all that apply):
Glove Bagr b.Encapsulation I— c.,EnCl u• ' 1.
Disposal
Only I' e,Cleanup
"' 1 w Full Containment g. Other-Please Specify:
13. J L 'is being, on .rr t d: A a., Indoors r b. Outdoors
14 . Total amowit of each type of asbeaos Containing r at ri l AC to be rerrioved,enclosed,or
0 10
.Linear Feet(Lire,Ft.) 2,Square Feet Sq.,Ft.
1 .Boiler,Br hir ,Dtict, c.Transit Pipe
T'' nl,Surface Coatings I,.LIn,Ft.. 2.Sq.Ft. 1.Lin.Ft. Z Sq.Ft.
d.Pipe.Insutatioll 190 e."I"ransite Shingle
1I Lin.Ft. 2.Sq.,Ft. I.Lin.Fta .Ft.
f, Spray-On Fireproofing g.Transit Transite Panels
1 Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
lira Cloths,Woven Fabrics i.Other-Please Specify,
1.Lire.Ft. .Sqw Ft,
j. Insul titrg C the t
1 Lin.Ft. I Sq.Ft. 1.Lin.Ft. 2.Sq;.Ft.
15.Describe the decontamination system(s) to be used:
TI-iREE CHAMBER DECOR'
16, Describe the con taitwri tion is sposal niethods to cornp,lywith 3 l MR 7.15rid 453 C R 6.1 2)
g :
6 MIL,POLY'
1 .:F r Emergency Asbestos,Operations,the l l and DLS officials who evaluated the emergency:
.Name of Mass,DEP Official b.Title of MassDEP Official
.Date of Authorization, III' /I ,I dY" ' 'I i.Waiver
A Name of ILLS Official f,Title of DLS Official
q.Date f Authorization / YYY') h,Waiver
1 ® Do prevailingwage rates as per M.G.L.c. 149, §26 27or -F apply to this w ..Yes I` .No,
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Rev iel: 11, 1 13Page 2 of' ,
F
Massachusetts Department of Environmental Protectioll
100308180
BWPAQ 04t' ANF-001) Asbestos Project#
. Asbestos Notification Form Project Revision
r Pr *ect Cancellation
B. Facility Description
1.Curren,t or prior use of facility RESIDENTIAL
the fa .lit owner-occupied residential,with.4 units orless? r y ,.Yes ' K No
.PATRICIA GLYl l 73 BIND STREET R
a.Facility Owner Name bi.Address
NORTHANDOVER ILIA 01845 9787646692
.City/Town City/Town d.;state e.Zip Gode f*T I phone
PATRICIAGLYNN 73 BRA STI FFT R
4. .Name of Facility Owners Ors-Site Manager er .,Address
f
NORTH ANDOVER MA 01845 9787646692
.City/Town d.State .Zip Code f.Telephone
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N/ 1
. .Name of General Contractor b.address
N/A MA 01845 1111111111
.City/Town d.State e.Zips Code f.Telephone
l<
. ontr t r's,Worker's ompens,tion Insurer
NIA 12/31/2019
h,Pollicy# f.Expirafloin Date MM/D
. What is the size of this fa ilia
.Square Feet bM#of Fl l r
Not :Tr parr
storage of Asbestos C. Asbestos Transportation Disposal
containing:wt .Trans. porter t•t 1 "a t a r tait�ilg ; t t trial fromsite of Brat it
material is only
,allowed at the place a.Directly to Landfill or IV b.To"rempor r Storage I ati n/T ransfer Station
f business +f a DL
licensed Asbestos
contractor, r a transfer AIR SAFE:INC 22 WILLOW ST
station'that is c.Fame of Transporter TAddress
permitted by
MassIDEP and CHELSEA MA 021507 3 1 �
operated ll �. it �"T rn f.State: .Zip Code h Telephone
complianceith Solid
'4 to Regulations,
19.000
. If a ternporary storage ra location/transfer t ti n is used,list name of transporter of asbe,s,tos Containing
waste material from temporary st a 10 .tion/tr an f r t bon t l final disposal site:
SERVICE TRANS GROUP 301 OXFORD VALLEY RD SMITE 80
.Name of Transporter b,Address
AR LE "' IAA 19067 7 ,
.City/Town d.State e.;alp Code t.Telephone
Revised: 11/13/2013 Page 3 of
Massachusetts Departinent of Envixonmental Protection
oil
10,103081,80
BWP AQ 04 (A,NF-0011,.)
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AsbestosPry~ j
Asbestos,Notification Forrn I" Project Revisioii
ProJect.Cancellafion
..Natne clind,address of temporary t rag location/transfer station for the asbestos containing waste,
material,:
II .SAFE INC WILLOW ST
.Temporary r Storage Location Name b,Address
c.City/Town d.State .Zip Code f,Telephony
.N,ariie and location of final disposal site(asbestos landfill):
MI'NERVA LANDFILL MINE MINERVA ENTERPRISES,I ,
w Final Disposal Site Name bbFinal Disposal Site Owner Name
c.Address
WG CH 44688 330B663435
d,City/Town e.State, f..Zip Code g.Telephone
Note:Contractor,must
sign this form for i L a
nfifitln purposes
. Certification
DFW DFW
"'I certify that I have personally 'I.lime ',authorized Signature
examined the foregoing and am BSI 1 /21
familiar with the information
contained in this document and 3.Po ltio n/Titl b Date / )
all attachments,and that, based 9783395361 AIRSAFE INC
on,my inquiry of those .Telephone 6 Representing
entin
individuals immediately 23 WYCHWOODDRIVE LITTLET N
resiponsible for obtaining the 7.Address .,City/Town
information, I believe e that the MA 1
460
information tion is true„accurate,and
eorn, �lete. Iate:agar that there �State .dip fed
are significant penattles for
submitting false iiniformation,
including passible fines and
imprisonment.nment.The lunder igned
hereby stators that l have read the
Commonwealth oaf
Massachusetts regulations
governing governi'ng asbestos abatement
t.
(453 C.MR 6.00promulgated by.
the Department of Labor
Standards and 310 CMR,7.15
promulgated by the Department
of Environmental I roteetio n:),,
and that l am aware that this
permit application or notification
shall not.be deemed valid
unless payment of the
applicable fee is made."
Revised; 1,1/13/2013 Page 4 of