HomeMy WebLinkAboutMiscellaneous - Exception (199)r
Air Quality Experts, Inc.
AUGUST 4, 1992
349 So. Broadway • Suite #8
Salem, New Hampshire 03079
NO. ANDOVER BOARD OF HEALTH
120 MAIN STREET
NO. ANDOVER, MA 01845
DEAR SIR:
Asbestos Removal
Residential • Commercial • Industrial
My-,
F L7
-
ENCLOSED PLEASE FIND COPIES OF MA. ASBESTOS NOTIFICATION FORM
FOR ASBESTOS ABATEMENT WORK TO BE PERFORMED ON UGU& --2,, 1794-4-z.
s'lP7- i 992 -
IF YOU HAVE ANY QUESTIONS CONCERNING THIS MATTER PLEASE CALL!!
SInNC/ERELY,
CHRISTOPHER THOMPSON
PRESIDENT
Commonwealth of Massachusetts
Asbestos Notification Form ANF -001
X ,
Asbestos Abatement Description b
1 Facility location:
�� .. .......
.......... ...............................................
.............................................
INSTRUCTIONS Name J Address
1. All sectionsolthis 1�.0 ............................................... .......... 0 -La ..5 .................... 6.133 .........
form must be completed City/Town Zip code Telephone
in order to comply with
the Department of ........... : ..........................
Environmental -WIAN'111; ivirtile locajoll?, .................... ....................... * ............. ** ...................... ...........
Protection notification 2. Is the facility occupied?a<e, 0 No
requirements of M CIAR
7.15 (ten working days
prior notification is 3. Asbestos Contractor:
requited ofary abatement AIR QUALITY EXPERTS, INC. 349 SO. BROADWAY #8
projecl); and the .................................................
Department
of Labor Name Address
and Industries
notification requirements SALEM, NH' 03079 603-894-6465 ..........
of453CMR 6.12 (ten Cirygown Ziv rode Telephone
days prior notification is
niquiradol'ANY AC 000167 WRITTEN
abatement project greater I ...._ I ... ..... .. ... . ... ............. ....................... ............................. ................... ..........
than Wee linear or DtlLkefisel Contract Tyle Willeroeta)
square faeo. 4. On -Site Project Supervisor/Foreman:
2. Submit Or iginal Form CHRISTOPHER THOMPSON SF07797
To:
Commonwealth of
Massachusetts 5. Project Monitor:
Asbestos Program
P.0.9.120067.../
Boston, MA 02112- Nalfre DUCeffificalioul
0087
6. Asbestos Analytical Lab:
3. This form maybe
usedfor notifying the ............ ......................................................... ......................................................
U.S. EnvironmentalNarne DU Certification/
Protection Agency Region -li*m
I of asbestos demolitioruf 7. Projejt stan oat e_L�/2eddate _4�specific work hou rs (Mon.-
Sun.)
renovation operations f/ I / 121 2—
subject to NESHAPS (40
CFR Subpart M). 8. What type of project Is this? (circle one): demolition repair enovalion ollier(explain)
rot 0681 Use ony 9. Describe the asbestos abatement procedures to be used (circle kglovebag enclosure full containment cleanup
encapsulation disposal only oflier(explain)
Noikagon I
RK&W Dale 10. Is the job being conducted 01n`d/oors Coutdoors?
Rwwei
Paw Awweall)wed 11. Total amount of each type of Asbestos Containing Materials (ACM) to be handled on pipes or ducts (linear ft.) Ino or other
surfaces (square ft.) to be removed, enclosed or encapsulated:
I linear/square feet
boiler, breaching, duct, tank surface coatings... thermal, solid core pipe knulation .......
corrugated or layered paper pipe insulation .... /00/ insulating cement ..................
spray -on fireprooling ..................... trowellsprayer coatings ..............
cloths, woven fabrics ..................... fransile board, wall board .............
other (please describe) ...................
12. Describe the decontamination system(s) to be used:
qL0 V E 0r{ C.
.. ....... .............. ........ .. .. .
............................................................................. . ............................... ............................................................... .............
............... I I ............. ................
13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(8):
WET REMOVILL I.N.T.Q 6KIL ROLY A.SBES.TOS. LABELED BAGS ............. ! ....................................
..... ....... . I ... -. I - .................. .................. .
114. For Emergency Asbestos Abatement Operations, the DEP and DLI officials who evaluated the emergency:
Name of DE P 0 1 ho a itde
i*Wi;***'*..........z..................................'W;i' ""**'*"* ................ ........................�;WZ1ii�L;�;I
........... ii ...................... ...................... I ............... .................. I ..........
Nacre of
Wria rifle
........................................................... ......... 1.
Wilvetl
15. Do prevailing wage rates apply as per M.G.L. c. 149, § 26, 27, or 27A - F to this project? 0 Yes 0 No
Rev. 6)92 .
Facility Description
1. Current or prior use of facility:
ES' PENCE
.............................................................. ......................................................................................................... :..........................................................
2. Is the facility owner -occupied residential with 4 units or less? C9Ies f3 No
3. Facility Owner:
Name
Address
Civrown lip cafe Telephone
4. Facility's Owner's On -Site Manager:
....
Narne Address
.................y......../......................................................................................................................................................................................................
City ewrr Zip cWe Telephone
5. General Contractor:
r.............................:...............................................................................................................................
Name j Address
CiryRown Zlp code Teteph one
Contractor's Workers Comp. Insurer Policy/ Exp.Date
6. What is the size of the facility?0� 00 (sq ft) 2, (k of floors)
13 Asbestos Transportation and Disposal
1. Transporter of asbestos -containing waste material from site to temporary storage site (if necessary) to final disposal site:
AIR QUALITY EXPERTS, INC. 349 SO. BROADWAY #8
........................................................................................................................................................................................................................................
Narne Address
'SALEM, NEW HAMPSHIRE 03079 6031'894-6465
......
Cilyyrown lip rale Telephone
2. Transporter of asbestos -containing waste material from removal/ temporary storage site to final disposal site:
SAME $
...........................................................................................................................................................................................................................:.............
Name
Note: Transfer
ciry/rowr,
Zip rode releprrone
Stations must
3. Refuse transfer station and owner (if applicable):
comply with the
Solid Waste-
'
Division reuta
9
....................................................:'.......................................
Name
....................................................................................................................................
Address
tions 310 CMR
/18.00
................................. ................... .....................................
....................................................... .....r....................................................................
own
f
Zip axle Telephone
4. Final Disposal Site:
TURNKEY LANDFILL
WASTE MANAGEMENT OF NEW HAMPSHIRE
.........................................................................................................................................................................................................................................
Laation Name
timers Narne
90 ROCHESTER NECK RD.
..........................................................................................................................................................................................................................................
Address
ROCHESTER, NEW HAMPSHIRE
03867 603-332-2386
r1y1Tmm
............................
lin code Te/enhone
Certification
The undersigned hereby states, under the penalties of perjury,
that he/she has read the Commonwealth of Massachusetts Regulations
for the Removal, Containment or Encapsulation of Asbestos,
453 CMR 6.00 and 310 CMR 7.15, and that the information contained in
this notification is true and correct to the best of his/her knowledge and belief.
CHRISTOPHER THOMPSON
I/
C /� s fio to Itm Jg . Z
°
Print Name
...............:.................................1.........................:..9..............:..........
AuMorlred Si.4nature Date
Note: Contractor 6 0 3— 8 9 4— 6 4 6 5
must sign this PRESIDENT AIR QUALITY EXPERTS, INC.
form for DLI.....................................................................................................................................................................................................................
Poslliordrll/e Represenlfrryl telephone
notification
purposes 349 SO. BROADWAY #8 SALEM, NH 03079
........................................................................................................................................................................................................................................
Address firy/rowrp lip axle
Fee exempt (City, Town, district, municipal housing authority, owner -occupied residential of four units or less) ? es 0 no
Sticker I (from front of form): Q 6 113