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Home My WebLink About0104 PARK STREET - Health '104 PARK STREET Hyannis A A= 327 -203 Massachusetts Departtnenr of Envir mental Protection „ ---100254650 ---- BWP AQ 0 ANF-00t) Asbestos Notlfi ation Form Asbestos Project# ILProject Revision • ` . v �: J� ( ; Project Cancellation A. Asbestos Abatement Description I. Facility Location: ENT REAL ESTATE LLC 104 PARK ST. Instructions 1.All a.Name of Facility b.Street Address sections of this form HYANNIS MA 02601 5083649639 must be completed in order to comply with c.Cityrrown d.State e.Zip Code f.Telephone MassDEP notification SAME AS ABOVE O\/AER requirements of 310 CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title Department of Labor WorksiteLocation: OFFICE MEDICAL CTR Standards DLS notification i.Building Name,Wng,Floor,Room,etc. requirements of 453 2. Is the facility Occupied? J_,a.Yes NF la.No CMR 6.12 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)? r- a.Yes I✓ b.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 Massachusetts 6.Asbestos Contractor: P.O.Box 4062 Boston,MA 02211 ASBESTOS MAN REMOVAL 929 STATE ROAD a.Name b.Address PLYMOUTH MA 02360 5082245500 c.Cityrrown d.State e.Zip Code f.Telephone A0000342 h.Contract Type: 1.Written r%_�2.Verbal g.DLS License# 7. ELMER E,PINEDA AS001291 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8. N/A a.Name of Project Monitor b.DLS Certification# 9. N/A a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 11/22/2016 11/22/2016 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 3PM-9PM 3PM-9PM c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11. What type of project is this? I"" a.Demolition W b.Renovation r c. Repair r d. Other-Please Specify: Revised: 11/13/2013 Page 1)of 4 Massachusetts Department of Environmental Protection 1100254650 BWP AQ 04 (ANF-001) bestosProject# Asbestos Notification Form T7 Project Revision ( " Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): Jv a.Glove Bag 17. b. Encapsulation r. c. Enclosure ri d.Disposal Only ; e.Cleanup (` f.Full Containment ) g.Other-Please Specify: 13. Job is being conducted: ,. a. Indoors r b. Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 75 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation 75 e.Transite Shingles 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f.Spray-On Fireproofing g.Transite Panels 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h.Cloths,Woven Fabrics i.Other-Please Specify: 1.Lin.Ft. 2.Sq.Ft. j. Insulating Cement 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15.Describe the decontamination system(s)to be used: REMOVE ASBESTOS USING THE GLOVEBAG METHOD 16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): WET DOWN ASBESTOS AND DOUBLE BAG USING 6 MIL MARKED NAD LABELED BAGS 17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18. Do prevailing wage rates as per M.G.L. c. 149, §26,27 or 27A—F apply to this a.Yes b.No project? Revised: 11/13/2013 Page 2 of Massachusetts Department of Environmental Protection - '' 1100254650 .__., BWP AQ 04 (ANF-001) w.-. . _ ........ Asbestos Project# �`` Asbestos Notification Form Project Revision a Project Cancellation B. Facility Description I.Current or prior use of facility: MEDICAL CTR. 2.Is the facility owner-occupied residential with 4 units or less? r7 a.Yes IV b.No 3 SAME AS ABOVE 30 ALDRIN RD. a.Facility Owner Name b.Address PLYMOUTH MA 02360 5083649639 c.City/Town d.State e.Zip Code f.Telephone 4.N/A N/A a.Name of Facility Owner's On-Site Manager b.Address N/A MA 02360 5083649639 c.City/Town d.State e.Zip Code f.Telephone 5.N/A N/A a.Name of General Contractor b.Address N/A MA 02360 5083649639 c.City/Town d.State e.Zip Code f.Telephone N/A g.Contractor's Worker's Compensation Insurer 99999999999999999999999999999999 9/9/9999 h.Policy# i.Expiration Date(MM/DD/YYYY) 2000 1 6. What is the size of this facility? a.Square Feet b.#of Floors C. Asbestos Transportation & Disposal 1.Transporter of asbestos-containing waste material from site of generation: (" a.Directly to Landfill or r b.To Temporary Storage Location/Transfer Station ASBESTOS MAN REMOVAL CO. 929 STATE RD. c.Name of Transporter d.Address Note:Temporary storage of Asbestos PLYMOUfH MA 02360 5082245500 containing waste e.City/Town f.State g.Zip Code h.Telephone material is only allowed at the place of business of a DLS 2. If a temporary storage location/transfer station is used, list name of transporter of asbestos containing licensed Asbestos ora storage waste material from temporary location/transfer station to final disposal site: contractor or a transfer p ry g p station that is permitted by JOB ROLLOFF POB 609 MassDEP and a.Name of Transporter b.Address operated in compliance with Solid HAMPSTEAD NH 03841 6173871495 Waste Regulations 310 CMR 19.000 c.City/rown d.State e.Zip Code f.Telephone Revised: 1 1/13/2013 Page 3 of 4 Imo- - - -- ---- _-- - I Massachusetts Department of Environmental Protection 1100254650 _. BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form d s 3 Project Revision °" Project Cancellation C. Asbestos Transportation &Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: ASBESTOS MAN REMOVAL CO. 25 ADAMS ST. a.Temporary Storage Location Name b.Address BRAINTREE MA 02184 5082245500 c.City/Town d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): TURNKEY LANDFILL WASTE MANAGEMENT a.Final Disposal Site Name b.Final Disposal Site Owner Name 90 ROCHESTER NECK RD. c.Address ROCHESTER NH 03839 6033390039 d.City/Town e.State f.Zip Code g.Telephone D. Certification PAULILACQUA PAULILACQUA "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PRESIDENT 11/9/2016 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) Note:Contractor must sign this form for DLS all attachments and that, based 5082245500 AMR CO notification purposes on my inquiry of those 5.Telephone 6.Representing individuals immediately 929 STATE RD. PLYMOUTH responsible for obtaining the 7.Address 8.City/Town information,I believe that the MA 02360 information is true, accurate,and complete. I am aware that there 9.State 10.Zip Code are significant penalties for submitting false information, 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: 1 1/13/2013 Page 4 of 4