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Home My WebLink AboutLegal Document - 340 WOOD LANE 9/3/2015 09/02/2015 11:50AM 5442 DAVE WALSH PAGE 82/06 AQ 04-Asbestos Removal Notification Fonn ANF-00l-Tmasactioo— ��-gov/WebFon-ns/Asbestos/BWPANFOOl.cspx Commonwealth of Massachusetts Asbestos Project Number Asbestos Notification Form ANF-001 Project Revision Notification P, Project Revision M,, Project Cancellation MOM A. Asbestos Abatement Description 1. Facility T | � Name ofFacility Stmm^moma Cityrr»wn state Zip Code Telephone lhatructions 1,All Facility Contact Person Name paa|ar Contact Person Title sections m this form must VVb/ks|bxLoocd|on: bn completed io order m Building Name,Wing,Floor,Room,ate. comply wi*m,""oep notification requirements 2. Blanket Permit Project Approval, |fapplicable: �----~'------' of 310 CNR T.15 and Approval/wx =pa"**mw Labor 3. Non-Traditional Asbestos Abatement Work Practice Approval, If applicable: Standards(01-8) �un�vm�Q#� �~ L�| -__ -__ - - notification requirements, ____-_--------------- m«mrIVIR 0.12 Project Start Date 0mM/Dnnr, End Date(MM/ooxYvY INA Work Hours'Monday Through Friday w*rkxovm-Sao mar«ounouv wassusv Use Only Date Received B. Other Project Revisions: Submit Original Form To! Commonwealth of Massachusetts P.O. Box*uou Boston,wm 02211 CCertification'1vumfymot/xmepersonally examined ----~--- ----- the foregoing and amwmmw/with the m«m, AUthoriZed Signature Note:Temporary information contained m this document ............. storage o/Asbestos and all vVam`mvn*and that,based on ^ mm/akin/nwwome my Inquiry of those individuals p»u«on«nm Date Vwwvoonv,v _ � __ my�nu/�vn�onuwe mmeme��onun�V�m,ob�wng 62��0 y ��y�� m the place of the information,|believe that the Telephone Representing v*omuommao/a information/s true,accurate,and licensed Asbestos uomv/ww.|am aware that there are - ----------- contractor urutransfer significant penalties for submitting false Address cltynro~^ ' station that ispermitted information,including Possible lines and 4/waaaaenand Imprisonment.The undersigne hereby State Zip Code operated mcompliance states that/have read(he with Solid Waste VvmmvoweanoorMassachusetts eeou/*iomoo1vCmn regulations governing asbestos 19.000 abatement(4sooMR000promulgated hy the Department or Labor Standards and a1ouwRr'1s promulgated uythe Note:Contractor must Department orEnvironmental sign this form for nLo pro,ection).and that/om aware that Received Time Sep, 2, 2815 1 : 04PM N8. 1383 1of2 9/2/2~ ^ J^/ 8 )5 |. _ � 1235 PM � ) 09/02/2015 11:50AM 5442 DAVE WALSH PAGE 03/06 AQ U4-Asbestos KeMOvat Notltication t'orM .Ater-UUI- Iransactt011... ntZps:creaep.oep.masS.govi woor"Uri10ASUCSLUSIDW r iNrvvimz�p; ANON Commonwealth of Massachusetts 100227395 Asbestos Notification Form ANF-001 Asbestos Project Number I I Project Revision Pro 1 act Cancellation i A. Asbestos Abatement Description 1. Facility location: 'MAUREEN ROCHE Name of Facility Street Address NORTH ANDOVER 1 i01e45 1978-979-2070 Cityrrown State Zlp Code Telephone Facility Contact Person Name Facility Contact Person Title Worksite Location: BASEMENT InaVUCtlons1.All �_.........-•------.__..;.,.._...__._.__.._._.._.........,:,:.--'----._...__...._._._.: sections or this form must Building Name,Wing,Floor.Room,etc. be completed in order 0 coMplywnh MBssDEP 2. Is the facility occupied? i„Y!.I Yes _r: No notification mquiremeMs of310 CMR7.15 and 3, Is this a fee exempt notification (city,town,district_,municipal housing authority,state facility,or owner- DepanmentofLabor occupied resldential roe of four units or less)l t'. iYes i No property KY ) _.._ L.._... Stenddrds(DLS) --....._.,_.....,,,.,--------------- noll4cation requirementB 4.Blanket Permit Project Approval,if applicable: of 453 CMR 6.12 Approval ID# 5_ Non-Traditional Asbestos Abatement Work Practice Approval,if applicable: Approval ID# MaesDEP Use Only °- 1 6.Asbestos Contractor: ...._, :. .._..._.... . DateReceived i - ' t _._...,_- -••------------------•----._._........ . ----•------'---1 Name Address _.__.. 2.Submit Original CltyRown State Zip Code Telephone FormTo: _.._......__:...-..............__.....t. _..__._..._.... ..,_ Commonwealth of :.......,. -::_.._...__.._.i Contract•type:;N.'Written:! 'Verbat DLS License# ° - _-- -• - - Massachusetts P.D. -^ Box 4062 Boston,MA 7, t ,' AS0e0847 ...._.__..........-----.._._:::_......__._.......; 02211 Name of Contractors on-Site SupervisorlForeman DLS Certifloetlon# 8. _.......-T-..._._.._... r Z.. _.. 0 77 Name of Project Monitor DLS Certification# ;AA00012B 9 : _ .... .. .... Name of Asbestos Analytical Lab DLS Certification tk -----°----._._.,:-.__...------••---------._.,.:,...,,-----------------.._.,....,.•� 10910412015_,...:__..___..._.......__..._.....,.�: ! 10.;0910412015 .-. . .......� ....._._.._.,.._..._.... _..., ..........._............- - _....._....._..:_, Project Start Date(MMIDDIYYYY) End Date(MMIDDNYYY) ...�..-,................_........... ......w....,. ANA Work Hours-Monday Through Friday Work Hours-Saturday&Sunday 11_What type of project is this? P i Demolition :J�Renovation ;V'-i Repair I E13!Other-Please Specify: I 12.Abatement procedures(check all that apply): 1 I% p y ; ue1;Cleanup :;i Full Containment Glove Bag l Fi i EneapsulattOn --,Enclosures ,�_i�Disposal Only ; .. .................._ ._...,.... _.,...,,., . .._... ,.....,.,......., . .._... Other-Please Specify' Received Time Sep. 2, 2015 1 : 04PM No. 1383 8i24/2015 7:31 PI I of 4 09/02/2015 11:50AM 5442 DAVE WALSH PAGE 04/06 A%qu4-AsneST OSKemOValNOTITll:dtlonruneNrvr-vvI- irarlsaUtUn.,. 11 ttp5:t/outp.uep.ijkm S.guvi wt urVll vvrtiairvvI.dip. B. Facility Description 1. Current or prior use of facility: 2, Is the facility owner-occupied residential with 4 units or less? _Ct i Yes ~i No 3. 'SAME SAME - - Facility Owner Name Address 'SAME MA 1 101645 i ;978.979.2070 _j Cityfrown State Zip Code Telephone 4. ;SAME I !SAME Narnd of Facility Owner's On-Site Manager Address (SAME iMA i 101845 1 1978.979-2071) Cityfrown State Zip Code 'telephone I NA NA Name of General Contractor Address ,NA ' MA i 101845 r 111-111-1111 -° -- Cilyfrown State Zip Code Telephone INA Contractor's Worker's Compensation Insurer iNA i 112131/2015 Policy# 6piratlon Date(MM/DDNYYY) 6.What is the size of this facility? ;1000 _..._._.. -- ?..:_. -- -°- - -- _ Square Feet #of Floors C. Asbestos Transportation & Disposal 1. Transporter of asbestos-containing waste material from site of generation: 15.;Directly to Landfill or I fj:To Temporary Storage LoCallonlTransfer Station -, 122 1 0 ST .AIR SAFE Name of Transporter Address ___.._._._..._.__._.._:.,--^•----....----...------------.----; 02150 1791762-3390 ICHELSFA IMA ._ i._..-- - _. --°............._........ _ - City/Town . State • Zip Code Telephone 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: rSERVICE TRANS GROUP -- _..•_ ,_ ._.^ __ ; 'S8 i RD - Name of Transporter Address ;NEWCASTLE 11DEMw- r 972 } c877-999-9559 Cityfrown State Zip Code Telephone 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: ;AIR SAFE t22 WILLOW ST Temporary Storage Location Name Address ...............^.,-...,,,.--___,...,,...-.I.....-i r.....:,...., _., CHELSEA + iMA c ;02150 ' 'bY31-762-3390 Cityrrown Slate Zip Code Telephone 4. Name and location of final disposal site(asbestos landfill), iMINERVA _ 'MINERVA ENTERPRISES,INC Final Disposal Site Name Final Disposal Site Owner Name gom MINERVA R0 Address Received Time Sep, 2. 2015 1 : 04PM No. 1383 8/24/20157:31 Pn 2 of 4 09/02/2015 11:50AM 5442 DAVE WALSH PAGE 05/06 AQ 04-Asbestos Removal Notification Form.A.NF-001-Transaction.,. https;//edep.dep_mass.gov/WebForms/Asbestos/BWPANPOO Laspr ot Asbestos conteinin IWAYNESBURG OH i W668 ;330-677-3435 waste material is only City/Town State Zip Code Telephone allowed at the place of �-°'- 13.Job is being conducted: tn!I Indoor8 Outdoors business of*MS t---I I--_J licensed Asbestos 14.Total amount of each type of asbestos Containing materials(AGM)to be removed, enclosed, or conlrsctor or a transfer encapsulated: _ sfatfon that is pwrrtiNed by 100--••�•-"`"_._.._ � `_.___--..•••------___.__. - ) WsaDCP and operated in Linear Feet(Lin.Ft.) Square Feet(Sq,l;t.) compliance with Solid --•---•-- -- Boller,Breaching,Duct,Tank I Translte pipe Waste Regulations 310 ;I Surface Coatings Lin,Ft, Sq.Ft. Lin.Ft. Sq.Ft. CIVA 19.000 - _-._.----_-- ..........__....__._-, .................... l Pipe Insulation •.100 I I Tranaite Shingles - - -- Y I Lin.Ft. Sq.Ft. Lin.Ft. Sq.Ft. Spray-On Fife Fireproofing i _ ` Translte Panels r p g t---------------..1 t_-- _' `-- .._._..- �' - Lin.Ft. Sq.Ft. Lin.Ft. Sq.FL Cloths,Woven Fabrics _._,_-___I l._.__...._�_.._,I Other-Please Specify: Lin.Ft. Sq.Ft. Insulating ._ t :--•._--_ g Cement I 1 I t �. . .. 1 L.. -._.... Lin.Ft. Sq.Ft. Lin.Ft. Sq.Ft. 15. Describe the decontamination system(s)to be used: 13 CHAMBER DECON i i i 16. Describe the containerisation/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(9):.- - - 16 1L111 POLY BAGS _ - I I Note:Contractor must -- - ------------- sign(his form for DLS notification purposes 17. For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: , Name of MaseDEP Official Title of MassDEP Otricial Date of Authorization(MMIDDfYYYY) Walver# I Name of DLS Official Title of DLS Official _e.....-•• •--•--------._...._....---•� ;-°_..---...__...__..........:....,,.,-...-.......-_........................................___........... I . Date of Authorization(MMIDDNYYY) Waiver# 18. Do prevailing wage rates as per M.G.L.c. 149,§26, 27 or 27A—F apply to this Yes s I No r"_j D. Certification "I certify that I have personally examined ;DEW I the foregoing and am familiar with the Name Authorized Signature information contained In this document ---_._.__.__.___..___. , rVP __l ar)d all attachments and that,based on ""'""-"-"-""-•-•-__.-' "'--- m inquiry of those Individuals Position/Title Date(MWI)D/YYYY) Y q ry r-----._.-_--° .... _ - Immediately responsible for obtaining t78�_762_3390- _ 'AIR SAFE,INC_ _ j the information,I believe that the Telephone Representing Information is true,accurate,and _.,•-._,--.•..-,M.--.,. --------------- Information _m---.--•---•----•- 22 WILLOW SL CHELSEA i complete.I am aware that there are Address Cityrfown significant penalties for submitting false -- -- -- --._.. - CMA 102150 Information,including possible fines and -----------.-•--- --_. _— .__w.r..-°-°------•---°-•-----••-' imprlsonment.1'he undersigned hereby State Zip Code Received Time Sep. 2. 2015 1 : 04PM No, 1383 3 of 4 8/24/2015 7:39 pN 09/02/2015 11:50AM 5442 DAVE WALSH PAGE 06/06 AQ 04-Asbestos Rexntoval Notifications Form ANF-001-Trarlsact:ion... https://edep.dep.mass.gov/WebForms/Asbestos/BWPANFOO l.aspx states that I have reed the Commonweelth of Massachusetts regulations governing asbestos abatement(453 CMR 0,00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department or Environmental Protection),and that I am aware that this permit application or notifloation shall not be deemed valid unless payment of the applicable fee is made." Received Time Sep, 2. 2015 1 : 04PM No. 1383 4of4 8n4/2015 7:39P1`