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Home My WebLink About0029 LEWIS BAY ROAD - Health 29 LEWIS BAY ROAD Hyannis A = 327 - 227 0 Commonwealth of Massachusetts ' 100208015R1 -�` Asbestos Notification Form ANF-001 Asbestos Project# Project Revision Notification ttr r Project Revision Project Cancellation A. Asbestos Abatement Description 1.Facility Location: TOWN OF BARNSTABLE 29 LEWIS BAY RD. Name of Facility Street Address Instructions 1.All BARNSTABLE MA 02630 0000000000 sections of this form City/Town State Zip Code Telephone must be completed in N/A N/A order to comply with MassDEP notification Facility Contact Person Name Facility Contact Person Title requirements of 310 Worksite Location: EXTERIOR CMR 7.15 and Department of Labor Building Name,Wing,Floor,Room,etc. Standards(DLS) 2.Blanket Permit Project Approval,if applicable: notification requirements of 453 Approval ID# CMR 6.12 3.Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: Approval ID# MassDEP Use Only 9/25/2014 9/26/2014 Date Received Project Start Date(MM/DD/YYYY) End Date(MM/DD/YYYY) 7-3 N/A 2 Submit Original Work Hours-Monday Through Friday Work Hours-Saturday&Sunday . Form To: Commonwealth of B. Other Project Revisions: Massachusetts Asbestos Program P.O.Box 120087 Boston,MA 02112- 0087 Note:Temporary storage of Asbestos containing waste material is only allowed at the place of business of a DLS licensed Asbestos contractor or a transfer station that is permitted by MassDEP and operated in compliance with Solid Waste Regulations 310 CMR 19.000 Revised: 11/13/2013 Page 1 of 2 i Commonwealth of Massachusetts 100208015R1 Asbestos Notification Form ANF-001 '7) `�,, � Asbestos Project# Project Revision Notification ryj Project Revision I_ Project Cancellation Note:Contractor must C. Certification sign this form for DLS "I certify that I have personally notification purposes examined the foregoing and am KEN FURTNEY KEN FURTNEY familiar with the information Name Authorized Signature contained in this document and PARTNER 9/25/2014 all attachments and that, based on my inquiry of those Position/Title Date(MM/DD/YYYY) individuals immediately 7813372117 NESM,LLP responsible for obtaining the Telephone Representing information, I believe that the 850 WASHINGTON STREET WEYMOUTH information is true,accurate, and Address City/Town complete. I am aware that there MA 02189 are significant penalties for submitting false information, State Zip Code 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 2 of 2 7LMassachusetts Department of Environmental Protection Bureau of Waste Prevention•Air Quality 1 -- BWP ANF-001 Pre-Form Notification Prior to Construction or Demolition r This is a revision to an existing form. Project ID for existing form to be revised: 100208015 This job is being conducted under a Blanket Permit MassDEP assigned Blanket Authorization ID: Fj This job is being conducted under a Non Traditional Abatement Work Practice Permit. MassDEP assigned Non Traditional Work Practice Authorization ID: I am a non-licensed contractor removing or disturbing non-friable shingles only. Ei None of the above conditions apply,generate a new form Revised: 11/13/2013 Page 1 of 1 r Commonwealth of Massachusetts 100208015 Asbestos Notification Form ANF-001 Asbestos Project# f r Project Revision Project Cancellation A. Asbestos Abatement Description P 1.Facility Location: t�1 TOWN OF BARNSTABLE 29 LEWIS BAY RD. Name of Facility Street Address Instructions 1.All BARNSTABLE MA 02630 0000000000 sections of this form Ci own State Zip Code Telephone must be completed in N/A N/A order to comply with MassDEP notification Facility Contact Person Name Facility Contact Person Title requirements of 310 Worksite Location: EXTERIOR CMR 7.15 and Department of Labor Building Name,Wing,Floor,Room,etc. Standards(DLS) 2, Is the facility occupied? r Yes ❑No notification requirements of,453 CMR6.12 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)? iJ Yes ❑ No MassDEP Use Only 4.Blanket Permit Project Approval,if applicable: Date Received Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, 2.Submit Original if applicable: Approval ID# Form To: Commonwealth of 6.Asbestos Contractor: Massachusetts NEW ENGLAND SURFACE MAINTENANCE 850 WASHINGTON STREET Asbestos Program P.O.Box 120087 Name Address Boston,MA 02112- WEYMOUTH. MA 02189 7813372117 0087 City/Town State Zip Code Telephone AC000196 Contract Type: RJ Written r Verbal DLS License# 7, KENNETH M FURTNEY ASO40208 Name of Contractor's On-Site Supervisor/Foreman DLS Certification# 8, N/A Name of Project Monitor DLS Certification# 9. N/A Name of Asbestos Analytical Lab DLS Certification# 10. 9/25/2014 9/25/2014 Project Start Date(MM/DD/YYYY) End Date(MM/DD/YYYY) 7-3 N/A Work Hours-Monday Through Friday Work Hours-Saturday&Sunday 11.What type of project is this? Demolition ❑ Renovation [ Repair ❑ Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 R� Commonwealth of Massachusetts 100208015 f Asbestos Notification Form ANF-001 Asbestos Project# ❑ Project Revision Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): Glove Bagj Encapsulationj Enclosure r Disposal Only r i; Cleanup r7 Full Containment C[ Other-Please Specify: 13.Job is being conducted: j Indoors Fyj Outdoors 14.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 6 Linear Feet(Lin.Ft.) Square Feet(Sq.Ft.) Boiler,Breaching,Duct, Transite Pipe 6 Tank Surface Coatings Lin.Ft. Sq.Ft. Lin.Ft. Sq.Ft. Pipe Insulation Transite Shingles Lin.Ft. Sq.Ft. Lin.Ft. Sq.Ft. Spray-On Fireproofing Transite Panels Lin.Ft Sq.Ft. Lin.Ft. Sq.Ft. Cloths,Woven Fabrics Other-Please Specify: Lin.Ft Sq.Ft. Insulating Cement Lin.Ft. Sq.Ft Lin.Ft. Sq.Ft. 15.Describe the decontamination system(s)to be used: AS REQUIRED 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): AS REQUIRED 17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: ANDREW COONEY INSPECTOR Name of MassDEP Official Title of MassDEP Official 9/19/2014 M-14-319 Date of Authorization(MM/DD/YYYY) Waiver# MELISSA BUTTS INSPECTOR Name of DLS Official Title of DLS Official 9/23/2014 10628-2014 Date of Authorization(MM/DD/YYYY) Waiver# 18.Do prevailing wage rates as per M.G.L.c. 149,§26,27 or 27A—F apply to this r yes ❑ No project? Revised: 11/13/2013 Page 2 of 4 4 Commonwealth of Massachusetts 100208015 Asbestos Notification Form ANF-001 Asbestos Project# Ll ❑ Project Revision F- Project Cancellation B. Facility Description 1.Current or prior use of facility: TOWN STREET 2.Is the facility owner-occupied residential with 4 units or less? I Yes r No 3.TOWN OF BARNSTABLE BARNSTABLE Facility Owner Name Address BARNSTABLE MA 02630 0000000000 Citylrown State Zip Code Telephone 4.N/A N/A Name of Facility Owner's On-Site Manager Address BARNSTABLE MA 02630 0000000000 City/Town State Zip Code Telephone 5.NESM 850 WASHINGTON ST. Name of General Contractor Address WEYMOUTH MA 02189 7813372117 City/Town State Zip Code Telephone Note:Temporary X storage of Asbestos containing waste Contractor's Worker's Compensation Insurer material is only X 1/1/2015 allowed at the place Policy# Expiration Date(MM/DD/YYYY) of business of a DLS licensed Asbestos 6.What is the size of this facility? 50 1 contractor or a transfer station that is permitted by Square Feet #of Floors MassDEP and C. Asbestos Transportation & Disposal operated in compliance with Solid Waste Regulations 1.Transporter of asbestos-containing waste material from site of generation: 310 CMR 19.000 G Directly to Landfill or ❑ To Temporary Storage Location/Transfer Station SERVICE TRANPORT 58 PYLES LANE Name of Transporter Address NEWCASTLE CE 19720 0000000000 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: Name of Transporter Address City/Town State Zip Code Telephone Revised: 11/13/2013 Page 3 of 4 Commonwealth of Massachusetts 100208015 Asbestos Notification Form ANF-001 Asbestos Project# 74Project Revision Project Cancellation note:contractor must C.Asbestos Transportation&Disposal: (cont.) sign this form for DLS notification purposes 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: Temporary Storage Location Name Address City/Town State Zip Code Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA ENTERPRISES MINERVA Final Disposal Site Name Final Disposal Site Owner Name 9000 MINERVA ROAD Address WAYNESBURG CH 44688 0000000000 City/Town State Zip Code Telephone A Certification "I certify that I have personally examined the foregoing and am KEN FURTNEY KEN FURTNEY familiar with the information Name Authorized Signature contained in this document and PARTNER 9/23/2014 all attachments and that,based Position/Title Date(MM/DD/YYYY) on my inquiry of those 7813372117 NESM,LLP individuals immediately responsible for obtaining.the Telephone Representing information, I believe that the 850 WASHINGTON STREET WEYMOUTH information is true,accurate,and Address City/Town complete. I am aware that there MA 02189 are significant penalties.for submitting false information, State Zip Code including possible fines and imprisonment.The undersigned hereby states, under the penalties of perjury,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