HomeMy WebLinkAbout0040 HIGHLAND AVENUE - Health (2) x
40. High'land Avenue
A= 020-032
Cotuit - --- - -- - - - - — --- - - --- - - - -
1
Commonwealth of Massachusetts
100120482
Decal Number
Asbestos Notification Form ANF-001
A, 1%20 -03
Importslin
ni When filling out. A. Asbestos Abatement Description
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? R Yes 0'No
to move your
cursor-do not b. Provide blanket decal number if applicable- Blanket Decal Number
use the return
key. 2. Facility Location:
VANHOESEN �40 HIGHLAND AVENUE
- a.Name of Facility b:Street Address
BARNSTABLE MA 02365
c.City/Town: d.State e.Zip Code f.Telephone Number
INslRucrloNs 3. Worksite Location: '
t-.AII section§of this BASEMENT
form must a.Building.Name/Building.Location b 'Building# a'Wing d.Floor e.Room
completed in order
to comply with 4., Is the facility occupied? 0 Yes No
DEP notification
requirements of 310
cMR 7.15 5. Asbestos Contractor: ,,
and:tne`Diyision NEW A ENGLAND;SURFACE MINTENNC AE 850 WASHGTN INO STREET'
of Occupational a
Safe DOS ;.
tY-( ) a.-Name b.-Address
notification WEYMOUTH 02189 78133721,17. :.
requirements of 453 � 4� '
CMR 6.12 C.
City/Town ', d.Zip Code e.Telephone Number r _
�AC000196 ,.. ,
V S
t:.pos-License Number . g`Contear, ype: D Wntten er,a
-::
h.Facility Contact Person i.Contact Persons Title
1PAULV AROWN 4S061945
a.Name of On=Sde Su ervisor/Forem �.9
6' an b.Su ervisor/Foreman DOS Certification Number 7.
PENNOR AM060445
a.Name of Pro'ect Monitor b.:Pro ect;Mondor DOS Certification,Number
j
FLI ENVIRONMENT AA000144"
8. a.Name of AsbestmArialytical Lab b.Asbestos AnalSlical Lab DOS Certification Number
02/21/2011 02/21/2011
,0 9' a.Prolect Start Date mm/dd/y b.End Date'(mmidd/y y
0 184pm i
N c.Work hours Mon-Fri. d.Work hours Sat-Sun.
_c 10. a.What type of project is this?
-o ❑ Demolition F� Renovation I
0✓ Repair ❑ Other, please specify: b.Describe
11. a. Check abatement procedures:
Q Glove,bag - Encapsulation
-0 0,Enclosure a__E]:.Disposal only a 't
ILL ❑.Cleanup. :_ _.. [].Other.specify. ._
0✓ Full containment--__.-,_w,__ �. _� r. b.Describe
Ll
�z ; ;
oQ 12 Is the iob`be-ing:conducted: M`Indoors? D Outdoorsy
0 anf001ap.doc•10/02 Asbestos Notification Form•Page 1 of 3
Commonwealth of Massachusetts ■
�100120482
Asbestos Notification Form ANF-001 Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
1135 30
a.Total pipes or ducts(linear tt) u. rotalother slur aces(square
c.Boiler,breaching,duct,tank E= 30
d.Insulating cement
surface coatings Lin.ft. Sq.ft. Lin.ft. Sq.ft.
e.Corrugated or layered paper 135 L
pipe insulation Lin.ft. Sq.ft. f.Trowel/Sprayer coatings Lin.ft. Sq.ft.
g.Spray-on fireproofing h.Transite board,wall board
Lin.ft. q.ft.. Lin.ft. Sq.
i.Cloths,woven fabrics ;j.Other,:,please specify:
Lin.ft. S ft. [' Lin.ft. Sq.ft:.
k.Thermal,solid core pipe I
insulation Lin,ft ,." Sq .ft: I.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 CM.R
IAS:REQUIRED
16. For Emergency Asbestos Operations, ttie?DEP and DOS officials who evaluated the.emergency:
�.
a.Name of DEP.Official b:Title.
c.Date(mm/dd/yyyy)of;:Authorization d-'DEP Waiver# :I
e.'Name'of DOS Qfficial" f.DOS:O rcial itle
�N.
g.Date(mm/dd/yyyy),of Authorization h;DOS Waiver#
o . 1:7. Do prevailing wads rates at per M G L.c. 149; §26,.27 or.27A-F apply to this project? F!Yes Q No
�0
B. Facility Description
_o 1. -Current or prior use of facility: RESIDENCE
�o
2. Is the facility owner-occupied residential with 4 units or less? Yes No
SAME
T 3' a.Facility Owner.Name b.Address
10 (�
1
o c.City/Town d.Zip Code e.Telephone Number area code and extension)
a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address
�Q c.City/Town d.Zip Code e.Telephone Number(area code and extension)
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L
Commonwealth of Massachusetts ■
100120482
Asbestos Notification -Form ANF-001 Dual Number
B. Facility Description (cont.)
5' a.Name of General Contractor b.Address
c.Ci /Town d.ZipCode e.Telephone Number area code and extension)
f.Contractor's Workers Comp.Insurer g.Pol�ber � hate(mm/dd/yyyy�
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
CINR 19.000 , RED TECHNOLOGY
a.Name of Transporter b.Address
o::City/Town d.Zip Code a Telephone Number
3: .
(a�Refuse�Transfer Station and Owner (b."Address
c.Ci /Town d Zi Code. e.Tele hone Number
4 MINERUA ENTERPRISES;INC. :
a Final Disposal Site Location Name b.Final;0 osal Site Location Owners Name.
9000:MINERVA ROAD WAYNESBURG;
c Final Disposal Site Address d.Ci /Town
OH 44688
e:State f.Zip Code g.Telephone Number
M
_° D. Certification
�N
The:undersigned.hereby states,under the JIM DOYLE
penalties of.perjury,that he/she has read the a.Name b.Authorized Signature
�o Commonwealth of Massachusetts regulations 2/8/2011 m
for the Removal,Containment or: c.Position/Title� d.Date(mm/dd/ww)
Encapsulation of Asbestos,453 CMR 6.00 and ( NESM
310 CMR7.15,and that the information,
contained in this notification is true and correct e.Telephone Number f.Representing
�� to the best of his/her knowledge and belief.
oq Address
IL
u_
�Z .
h.City/Town i.Zip Code
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