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HomeMy WebLinkAboutAsbestos Notification Form - Mass DEP - BWP AQ 04 (ANF-001) - Miscellaneous - 180 SUTTON HILL ROAD 9/18/2019 G/29/2g19/THU 10: 05 AM ERI FAX No. 6034895963 P. 001 - i i Environmental Restorations, InC. ,21 profession(approach to quaCty service (� FROM: fu� FAX: �� r (�' PAGES; (including cover) �] PHONE: DATE; © Urgent 0 For Revlew ❑ Please Comment ❑ Please Reply 0 Please Recycle VG � 110 16 Hazel Drive, Hampstead NH 03841--Tel (603) 329-6101—Fax (603)489-5963 www.environmentairestorations.com AUG/29/2019/THU 10: 05 AM ERI FAX No, 6034895963 P. 002 Massachusetts Department of Environmental Protection eDEP Transaction Copy Here is the file you requested for your records. To retain a copy of this file you must save and/or print_ Username: ERIDAwN Transaction ID: 1133169 Document' AO 04-Asbestos Removal Notification Form ANF-001 Size of File: 230.49K Status of Transaction: In Process Date and Time Created: gl WO19:5:00:02 PM Note: This-file only includes forms that were part of your transaction as of the date and time indicated above. If you need a more current copy of your transaction, return to eDEP and select to "Download a Copy" from the Current Submittals page. Reclewsv) G2gJp (0 0 N E AUG/29/2919/THU 10: 06 AM ERI FAX No, 6034895963 P, 003 Massachu8,___a Department of 1 nvirontnental Protection l BWP A.Q 04 (ANF-001)PreForm Asbestos Notification Form 7 This is a revision to an existing form. Project 1D for existing form to be revised: This job is being conducted under a Blanket Permit. MassDEP assigned Blanket Authorization 1D: F This job is being conducted under a Non Traditional.Abatement Work Practice Permit. MassDEP assigned Non Traditional Work Practice Authorization 1D: 1" This job does not require the use of an asbestos contractor licensed by the MA Department of Labor Standards because(please check one box below): r" This job involves breaking,shearing or slicing of non-friable asbestos-contaizairtg material only(e.g.cement shingles/panels,cement pipe,asphalt roofing or siding,vinyl floor tiles,etc.)in a manner that does not generate asbestos dust or render the material&fable,as allowed by the Department of Labor Standards(DLS)at 453 CMR 6.13(2)(a)5.,All work must be done in compliance with the applicable regulations at 310 CMR 7.15;or r This job involves work on asbestos containing material that is classified by the Department of Labor Standards (DLS)as a`Small-Scale Asbestos Project,' an`Asbestos-Associated Project',or an`,Asbestos Response Action' by qualified`in-house'personnel as allowed by the Department of Labor Standards(DLS)at 453 CN R 6.00,and will be performed in accordance with all the requirements of 453 CMR 6.13(1)(a),453 CN1R 6.13(2)(a)1.and 3., and 453 CMR 6.14(1)(a),as applicable_All work must be dome in compliance with the applicable regulations at 310 CMR 7.15. None of the above conditions apply,generate a new form. Revised: 11/13/2013 Page 1 of 1 AUG/29/2019/THU 10: 06 AM ERI FAX No, 6034895963 P, 004 Massachlts�,.s Department of)✓zlvizozazxlez�tai i'>otection( �100315040 BWP A.Q 04 (ANF-001) ° .Asbestos Notification Form Asbestos Project# 1"" Project Revision T" Project Cancellation. A. Asbestos Abatement Description 1.Facility Location: 180 SUTTON HILL,ROAD 180 SUTTON HILL ROAD Instructions 1.All a.Name of Facility b.Street Address sections Of this form NORTHANDOVF-R must be completed in MA 01845 8173594252 order to comply with c.Cltyrrown d.State e.,Zip Code f.Telephone MassDEP notification RICHARD BALLANTYNE OWNER requirements of 310 CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksitc Location: GARAGE Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc. requirementa of 4s3 2. Is the facility occupied? P a.Yes f 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)? 97 a-Yes F b.No MasSDEP Use Only 4.Blanket Permit Project Approval,if applicable: Data Received Approval ID# 5.Non-Traditional.Asbestos.Abatement Work Practice Approval, if applicable: Approval ID# 6.Asbestos Contractor: ENVIRONMENTAL RESTORATIONS INC 16 HAZEL DR a.Name b.Address HAMPSTEAD NH 03841 6033296101 C.City/Town d.State e.Zip Code f.Telephone ACOD0258 h.Contract Type: ;P 1.written F_2.Verbal g.DLS License# 7 STUARTGREGERMAN AS032645 a.Name of Contractors On-Site Supervisor/Foreman b.DLS Certification# 8 NIA a.Name of Project Monitor b,DLS CenlIcatlon# 9. NIA a,Name of Asbestos Analytical Lab b.DLS CertPgcatlon# 10. 9/11/2019 9/12/2019 a,Project Start Date(MM/DDlYYYY) b.End Date(MM/DD/YYYY) B;00 AM-4:30 PM NIA c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11.What type of project is this? F— a.Demolition F7 b.Renovation r c.Repair 7 d.Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 AUG/29/2019/THU 10: 06 AM ERI FAX No, 6034895963 P. 005 I; Massachusetts Department of Environmental Protection 100 SWP ,A.Q 04 (A,NF-001) 3150---4040 Asbestos Project# Asbestos Notification Form r-- Project Revision 71 !" 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- Disposal Only r e.Cleanup N,7 f Full Containment T- g.Other-Please Specify: 13.Job is being conducted: f' a. Indoors I- b.Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 700 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.Transitc Shingles 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f. Spray-On Fireproofing g.Transite Panels 1,Lin.Ft. a.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 GM WITH ACM TEXTIJRE 700 1.Lin.Ft. 2.Sq.Ft 1.Lin.Ft. 2.Sq.Ft. 15.Describe the decontamination system(s)to be used: 3 STAGE DECON WITH SHOWER 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): 6 MIL POLY BAGS MAILED LABELED 17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP 0MCIal b.Title of MassDEP Official c.Date of Authorization(MrNlDD/YYYY) d.Waiver it e.Name of DLS Official f.Title of DL5 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 r�7 b.No project? Revised:11/13/2013 Page 2 of 4 AUG/29/H 19/THU 10: 07 AM ERI FAX No, 6034895963 P. 006 Massachusetts Department of Environmental Protection 1100315040 L7IIBWP AQ 04 (ANF-001) .asbestos project# .Asbestos Notification Form C'" Project Revision 1" Project Cancellation B. Facility Description 1. Currant or prior use of facility: RESIDENTIAL, 2.1s the,facility owner-occupied residential with 4 units or less? .F a.Yes b.No 3 MARY&RICHARD 13ALLANTYNE� 180 SUTTON HILL ROAD a.Facility Owner Name .Address NORTHANDOVER MA 01645 6173594252 c.City/Town d.State e.Zip Code f.Telephone 4 N/A NIA a.Name of Facility Owner's On-Site Manager b.Address NORTHANDOVER MIA 01645 6173594252 c.Cltyrrown d.State ;..Zip Code f.Telepnone 5 ENVIRONMENTAL RESTORATIONS.INC. 16 HAZEL DRIVE a.Name of General Contractor b.Address HAMPSTEAD NH 03941 6033296101 c.Clryrrown d.Stets e.Zlp Code r.Telephone GRANITE STATE INSURANCE CO. g.Contractor's Worker's Compensation Insurer WC038411998 4/12/2020 h.Policy# 1.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 2800 2 a.Square Feet b.9 of Floors Not®:Temporary C. Asbestos Transportation & Disposal storage of Asbestos p p containing waste material Is only 1.Transporter of asbestos-containing waste material from site of generation: allowed at the place r' a.Directly to Landfill or 7 b.To Temporary Storage Location/Transfer Station of business oT a DLS licensed Asbeatos contractor or a transfer ENVIRONMENTAL RESTORAJTONS.INC. 16 HAZEL DRIVE station that is C.Name or Transporter d.Address permitted by MsasDF-P and HAMPSTEAD NH 03541 6033296101 operated in e.Clty/Tbwn f.State 7 7—poode h.Telephone compliance with Solid WAslie Regulations 310 CMR 19.000 ?_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 TRANSPORT GROUP 301 OXFORD VALLEY ROAD.STE 803E a.Name of Transporter b.Address YARDLEY PA 19067 2679999411 c.City/Town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 AUG/29/2.019/THU 10: 07 AM ERI FAX No, 5034895963 F, 007 � Asbestos 1Pl Massachusetts Department o�Environmental Protection 100315040� � BWP AQ 04 (ANF-001) Asbestos Notification Form evisio # ("" Project Revision J" Project Cancellation C.Asbestos Transportation&Disposal: (cont.) 3.Namc and address of temporary storage location/transfer station for the asbestos containing waste material, ENVIRONMENTAL RESTORATIONS,INC. 10 HAZEL DRIVE a.Temporary Storage Locallon Name b.Address HAMPSfEAD NH 03841 6033296101 C.City(Town d.State e.Zlp Code f.Telephone 4.Name and location of final disposal site(asbestos landfill), MINERVA ENTERPRISES MINERVA ENTERPRISES a.Final Diaposal Site Name b.Final Disposal Site Owner Name 8956 MINERVA ROAD c.Address WAYNESBURG OH 44608 3306663435 d.CItyrTown e.State f.Zip Code g.Telephone Note;Contractor must sign this form Tor OLS notlflcatlon purposes A. Certification STUARTGREGERMAN STUARTGREGERMAN I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am pM4E 812812019 familiar with the information 3.PositionlTRle 4,Date(MM/DD/YYYY) contained in this document and all attachments and that,based 6033296101 ENVIRONMENTAL RESTORATIONS,IN on my inquiry of those 5.Telephone 6.Representing individuals immediately 16 HAZEL DRIVE HAMSPTEAO responsible for obtaining the 7.Address 8.Cityrrown information, I believe that the NH 03841 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