HomeMy WebLinkAbout0197 BREAKWATER SHORES DR - Health 197 Breakwater Shores Dr.
A= 306- 143
Hyannis
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I
I � 4
I - Commonwealth of Massachusetts
100139094 -_-a
Asbestos Notification Form ANF-001 Decal Number
Important: A. Asbestos Abatement Description
When filling out P
forms on the
computer,use 1. a. Is this facility fee exempt-city, town,district, municipal housing authority, owner-occupied
only the tab key residence of four units or less? []Yes ❑No
to move your
cursor-do not b. Provide blanket decal number if applicable: Blanket Decal Number
use the return
key. 2. Facility Location:
VON DER LINDEN 1197 BREAKWATER SHORES DRIVE
a.Name of Facilitv F b.Street Address
_ hyannis MA 1 002061 -
c.City/i own d.State e.Zip Code f.Telephone Number
INSTRUCTIONS 3. Worksite Location:
1.All sections of this (ATTIC L�
form must be a:Building Name/Building Location b.Building# c:.Wing d.Floor e.Room
completed in order
to comply with . 4. Is the facility occupied? O Yes . No
DEP notification
requirements of 310
CMR T 15 5. Asbestos Contractor: ,
and the Division ri '
a Occupational . NEW EENGLAND SURFACE MAINTENANCE' 850 WASHINGTON STREET. t~
Safety(DOS) - a.Name jam apt _ b.Address
notification. WEYMOUTH — ,'02189 i:; 7813372117
requirements of 453
CMR:6.12. . c:City/Town :d.-
lip Code. e;Telephone'Number.
` AC000196� LCont 1Nrltten. Verbal'
f.DOS;License;Number., 9 .Contract Type:, ❑ ,Q.
I c
h:,Facili Contact Person i.Contact Person's.Title
IPAUL W. BROWN
6 -. mber
a.,Name of On Site Su ervisor/Foreman b.Su ervisor/Foreman DOS Certfication Nu
';. � PENNOR .° AM060445
7' a.Name.of P 'ect*Monitor b."Pr
ro ojectMonitor DOS Certification:Numbei
FLIENVIRONMENTAL. AA000144 " � k
8. a.Name of Asbestos Anal ical Lab b.Asbestos'Anal ical Lab DOS Certification Number .-
° 9' a.Project Start Date nim/dd/ - b.End Date mmldd/
o8-4
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c.Work hours Mon-Fri. d.Work hours Sat-Sun
�0 1G. a. What type of project is this? `
° ® Demolition F1 Renovation
✓[� '[:
Other;:Other; please specify:. b.Describe
11. a;•Check abatement procedures:
° t`
Q
Glove bag [] Encapsulation
—moo Q Enclosure El ❑ DisposalYonly -_.
.�.u
❑✓
Cleanup ❑Other,_speclfy:'#
-Full containment i b:Describe
—�z _
—Q 12. Is-the-job being conducted: [✓ Indoors?, ❑Outdoors?
anf001 ap.doc•10/02 Asbestos,Notification Form•Page 1 of 3
Commonwealth of Massachusetts _■
1.00139094
Decal Number
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.) -
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
0 11200
a.Total pipes or b. I otal otner surfaces square
c.Boiler,breaching,duct,tank
d.Insulating cement
surface coatings Lin.ft. Sq.ft. Lin.ft. Sq.ft..
e.Corrugated or layered paper =
Trowel/Sprayer coatings
pipe insulation Lin�ft. Sq.ft. f. Lin.
( ft. ( Sq.ft.
a.Spray-on fireproofing ' h.Transite board,wallboard L_v1
Lin.ft. Sq.ft. Lin.ft. Sq.n.
i.Cloths,woven fabrics �-- L — j.Other,please specify: 1200
Lin.ft. Sgsft.
I
k.Thermal,solid core.pipe VERMICULITE E
insulation" ::. Lin:ft. Sq..'ft. 1:Specify
14. Describe the decontamination systems)to be used:
AS REQUIRED
15. Describe the containerization/disposal methods to comply with 310 CMR.7.15 and 453_CMR
6'14(2)(9)
AS.REQUIRED`.
16.. For Emergency Ao6stos0perations the DEP and DOS officials who;evaluated the emergency:
COLLEEN FERGUSON INSPECTOR
-`• a:Name of:DEP,Officiar. b..Title
12/01/2011 SE-11=351'
c.Date(mm/dd/yyyy)of Authorization d.DEP Waiver#
MELI$SA BUTTS.. . INSPECTOR
e.Name of DOS Official .DOS Official Title,
12/01/2011 185072011
N g.Date(mm/dd/yyyy)of:Authorization h.DOS Waiver#
_0 17. Do prevailing wage.rates as per M.G L.�c 149 §26, 27 or 27A-F apply to this project? Yes E�/]No' `
B. Facility',Description
�N -
�0 1. Current or prior use of facility RESIDENCE
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2. Is the facility owner-occupied residential with 4 units or less? ` ❑✓ Yes ❑ No
SAME
a.Facili Owner Name; b.Address
�o
o c.City/Town d.Zip Code e:Telephone Number(area code and extension)
®LL 4' a.Name of Facili Owner's On-Site Manager b.On-Site Manager Address
�Q c.City/Town d.:Zip Code e.Telephone Number(area code and extension)
■ anf001ap.doc•10/02 Asbestos Notification Form•Pa e 2 of 3■
Commonwealth of Massachusetts
1100139094
Asbestos Notification Form ANF-001 Decal Number
B. Facility Description (cont.)
5.
a.Name of General Contractor � b.Address. . _
c.Ci /Town d.Zip Code e.Telephone Number area code and extension
f.Contractor's Worker's Comp.Insurer g.Policy Number h.Exp.Date m�m/dd/y
. What is the size of this facility?6 ry a.Square Feet b.Number of floors
C. Asbestos Transportation and .Disposal
1. Transporter of asbestos-containing material from site.to temporary storage site(if necessary):
NESM:
Note:Transfer a.Name of Transporter b.Address
Stations must
comply"with the c.City/Town d.Zip`Code e:.Telephone Number, _
Solid Waste
Division 2; Transporter of asbestos-containing waste material from;removal/temporary site,to;final disposal site:
Regulations 810
CMR 19.00.0 RED TECHNOLOGIES - 77
(a Name of Transporter b:Address
q% � =�
c Ci /Town d.Zi Code a Telephone Number'
� 3
a Refuse Transfer Station and Owner b Address
y
c.Ci`/Town d.Zip Code e.Telephone Number.
4 MINER�/A ENTERPRISES INC
a Final Dis osat Site Location Name b:Final Dis osal Site Location Owner s Name
9000.MINERUA-ROAD WAYNESBURG
`,c.Final"Dis osaLSde'Address d.Ci /Tows
pH 44688
e.State f.Zip Code, g.Telephone Number
�
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-o
D. Certification
N
The undersigned hereby states, under the KEN FURTNEY
�o penalties of perjury,that he/she has read the a.Name b.Authorized Si n� ature
�o Commonwealth of Massachusetts regulations 12/2./2011
for the Removal,Containment or c.Position/Title d:Date mm/ddA
Encapsulation.of Asbestos,453 CMR 6.00 and NESM
310 CMR 7.15,and that the information
contained'in this notification is true,and corfeCt e.'Telephone Number f.Re resentiri
to the best of his/her knowledge and belief.
�� .Address -
o _
v_
h.City/Town i.Zip Code
Z
�Q
anf001 ap.doc•10/02 Asbestos Notification.Form•Page 3 of 3