HomeMy WebLinkAbout0331 MAIN STREET (HYANNIS) - Health (2) 1
331 Main YStreet
Y A 32.7 '106
s, HYA
�''Ci
Commonwealth of Massachusetts ■
wr 100015991
Asbestos Notification Form ANF-001 Decal Number
Important:When filling out A. Asbestos Abatement ®esciiP tion
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 i No
to move your
cursor-do not ob. Provide blanket decal number if applicable: Blanket Decal Number
use the retumk ,I
key. Sa 2. Facility Location:
1 :CAPE COD TIMES 331 MAIN ST.
a.Name of Facility b.Street Address
BARNSTABLE MA 02601
c.City/Town d.State e.Zip Code f.Telephone Number
INSTRUCTIONS 3. Worksite Location:
;THROUGHOUT I
1.All sections of this I
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? '✓;Yes ` No
DEP notification
requirements of 310
CMR 7.15 5. Asbestos Contractor:
and of
Occupational
:NEW ENGLAND SURFACE MAINTENANCE 1850 WASHINGTON STREET
of Occupational
Safety(DOS) a.Name _ b.Address
notification requirements of 453 WEYMOUTH 02189 7813372117
CMR 6.12 : c.City/Town d.Zip Code e.Telephone Number,:
' •AC000196 ' —
_
f.DOS License,Number. .,. g. Contract Type: _ Written a al
h.Facility Contact Person i.Contact Person's Title
PAUL W BROWN 'ASO40577
6. a.Name of On-Site Supervisor/Foreman b.Supervisor/Foreman DOS Certification Number
r—
S. COHEN AM060787
7' a.Name of Project Monitor b.Project Monitor DOS Certification Number
ENVIROTEST LAB 'AA000128
8. a.Name of Asbestos Analytical Lab b.Asbestos Analytical Lab DOS Certification Number
�0 9 04/2712005 04/27/2005
a.Project Start Date(mm/dd/yyyy) b.bid Date(mm/ddlyyyy)
�O 8-4
�N c.Work hours Mon-Fri. d.Work hours Sat-Sun.
=o 10. a.What type of project is this?
�o t Demolition I✓I Renovation
— _ Repair Other, please specify: b.Describe
11. a. Check abatement procedures:
o -iI Glove bag 71 Encapsulation
Enclosure El Disposal only
Cleanup iJ Other, specify:
�Z
Full containment. b.Describe
_Q 12. Is.the job.being conducted: ✓i Indoors?--:!!Outdoors?
•,anf001 ap.doc•10/02••" ,, � - ' - , Asbestos Notification Form•Page 1 of 3
Commonwealth of Massachusetts ■
1100015991
i
Asbestos Notification Form ANF-001 Decal Number
Ll
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
0 "i 1120
a.Total pipes or ducts(linear ft) b.Totalouw surfaces square ft '
c.Boiler,breaching,duct,tank I 40 j
surface coatings Lin.ft. Sq.ft. d.Insulating cement Lin.ft. Sq.ft.
I� r
e.Corrugated or layered paper 1 f.Trowel/Sprayer coatings
pipe insulation Lin.ft. Sq.ft. Lin.ft. Sq.ft.
g.Spray-on fireproofing h.Transite board,wall board
Lin.ft. Sq.ft. Lin.ft. Sq.ft.
1 80
I.Cloths,woven fabrics 1 j.Other,please specify: i '
Lin.ft. S�� Lin.ft. Sq.ft.
k.Thermal,solid core pipe j j 1IIn01 I glue
insulation Lin.ft. Sq.ft. I.Specify
14. Describe the decontamination system(s)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 Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
� I
a.Name of DEP Official b.Title
c.Date(mm/dd/yyyy)of Authorization d.DEP Waiver#
e.Name of DOS Official f.DOS Official Title
g.Date(mm/ddlyyyy)of Authorization h.DOS Waiver#
�N ,
�0 17. Do prevailing wage rates as per M.G.L. c. 149, §26,27 or 27A—F apply to this project? ❑Yes No
B. Facali#�.1 Description
�N
MEMMOM— j newspaper facitity
�0 1. Current or prior use of facility:
�o
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes '`I No
331 Main St. Realty Trust 331 Main St.
3' a.Facility Owner Name b.Address
�o ;Hyannis ! 02601
o c.City/Town d.Zip Code e.Telephone Number(area code and extension)
4. a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address
c.City/Town d.Zip Code e.Telephone Number(area code and extension)
anf001ap.doc•10102 Asbestos Notification Form•Pa a 2q of 3 E
71 Commonwealth of Massachusetts ■
1100015991
Asbestos Notification Form ANF-001 Decal Number
B. Facility Description (cont.)
i
5.
a.Name of General Contractor b.Address
I
c.City/Town d.Zip Code e.Telephone Number(area code and extension)
I i '
� I
f.Contractor's Worker's Comp.Insurer g.Policy Number h.Exp.Date(mm/dd/yyyy)
I
6. What is the size of this facility? 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 310
CMR 19.000 'Red Technologies
a.Name of Transporter b.Address
c.City/Town d.Zip Code e.Telephone Number
3. I.
a.Refuse Transfer Station and Owner b.Address
I
c.City/Town d.Zip Code e.Telephone Number
4. MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name
9000 MINERVA ROAD ? 'WAYNESBURG
c.Final Disposal Site Address d.City/Town
!OH I 144688
i_Cn e.State f.Zip Code g.Telephone Number
�o
D. Certification
� of
The undersigned hereby states,under the ';Jim Doyle
�0 penalties of perjury,that he/she has read the a.Name b.Authorized Signature
�o Commonwealth of Massachusetts regulations
for the Removal,Containment or c.Position/Title d.Date fmmldd/vwv)
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15,and that the information i
contained in this notification is true and correct e.Telephone Number f.Representing
to the best of his/her knowledge and belief.
o g.Address
h.City/Town L Zip Code
anf001ap.doc•10/02 Asbestos Notification Form•Page 3 of 3