HomeMy WebLinkAbout0665 MAIN STREET (HYANNIS) - Health 665 Main Street
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Commonwealth of Massachusetts
100198212
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 M No
to move your
cursor-do not b. Provide blanket decal number if applicable:
use the return Blanket Decal Number
key.
2. Facility Location:
THE ELIHU STONE FAMILY TRUST 1665 MAIN ST. �>
a.Name of Facilit b.Street Address
,Am: HYANNiS MA1 102601 5087753388
c.City/Town d.State e.Zip Code f.Telephone Number
INSTRUCTIONS 3. Worksite Location:
1.All sections of this STONE ANTIQUES —� EXTERIOR 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? ❑Yes ❑✓ No
DEP notification
requirements of 310
CMR 7.15 5. Asbestos Contractor:
and the Division
of occupational ASBESTOS MAN REMOVAL 929 STATE ROAD
Safety(DOS) a.Name b.Address
notification pLYMOUTH
requirements of 453 P 02360 5082245500
CMR 6.12 c.Cit /Town d.Zip Code e.Telephone Number
AC000342
f.DOS License Number g. Contract Type: ❑Written ❑✓ Verbal
tPAUL
acili Contact Person i.Contact Person's Title ,�� ---t
6.
A ILACOUA AS050350
a.Name of On-Site Supervisor/Foreman b.Supervisor/Foreman DOS; p ertification_-Number
N/A j �
7' a.Name of Project Monitor b.Project Monitor DOS Certification Numb'e-T Q
N/A
$' a.Name of Asbestos Analvtical Lab b.Asbestos Analytical Lab DOTS Certification:Number
0 9. 5/16/2014 5/18/2014
a.Poj rt Ik1
� V
c Date mm/ddl
b.End Date mm/ddl
e�N c.Work hours Mon-Fri. d.Work hours Sat-Sun. `
�o 10. a. What type of project is this?
�o ❑ Demolition ❑✓ Renovation
❑ Repair ❑ Other, please specify: b.Describe
11. a. Check abatement procedures:
o
❑ Glove bag ❑ Encapsulation
o ❑ Enclosure ❑ Disposal only
�LL ❑ Cleanup ❑✓ Other, specify: ROOFING, CAULKING REMOVAL
—Z [IFull containment b. Describe
12. Is the job being conducted:.--Q j 9 ❑ Indoors? ❑✓ Outdoors?
anf001 ap.doc•10/02 Asbestos Notification Form•Page 1 of 3
Commonwealth of Massachusetts
100198212 e
Asbestos Notification Form ANF-001 Decal Number
Lik: r
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
200 2000
a.Total pipes or ducts(linear ) oT Ea�l ofTier suu aces ware
c.Boiler,breaching,duct,tank
d. Insulating cement
surface coatingsLin
.ft. Sq.ft. Lin S4L _�J
e.Corrugated or layered paper
pipe insulation Lin.ft. SqL ft f.Trowel/Sprayer coatings Lin.ft. Sq.ft.
g.Spray-on fireproofing --__J 1= h.Transite board,wall board
Lin.ft. Sq�ft. . ,p specify: Lin.ft.
i.Cloths,woven fabrics j Other, secif : 200 2000 -
Lin.ft. C:=
in.ft. So.ft.
k.Thermal,solid core pipe ��...� CAULK, ROOFIN
insulation Lin.ft. I.Specify
14. Describe the decontamination system(s) to be used:
COVER GROUND OUT 10 FEET FROM BUILDING WITH 6 MIL POLY
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
WET DOWN ASBESTO AND DOUBLE BAG USING 6 MIL MARKED AND LABELED BAGS
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a.Name�DEP fficial b.Title
c'.....-at e(mm/dd/yy )of Authorization d.DEP Waiver#
e.Name of DOS Official t.006 off icial TitTe
I
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 ✓Q No
B. Facility Description
o 1. Current or prior use of facility: ANTIQUE STORE
�o
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes ❑✓ No
�— ELIHU STONE FAMILY TRUST P.O.BOX 342
3' a.Facility Owner Name b.Address
o HYANNIS PORT 02647 5087753388
o c.Cit /Town d.Zip Code e.Telephone Number area code and extension
LL 4' a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address
�Z
Q c.Cit /Town
Y d.Zip Code e.Telephone Number(area code and extension)
anf001ap.doc•10/02 Asbestos Notification Form•Page 2 of 3
Commonwealth of Massachusetts
100198212
Asbestos Notification Form ANF-0 01 Decal Number.
B. Facility Description (cont.)
5' a.Name of General Contractor b.Address
c.City/Town d.Zip Code e.Tele hone Number area code and extension
f.Contractor's Worker's Comp. Insurer Polic Number h.Exp. Date mm/dd/
6. What is the size of this facility? 1 2000
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):
ASBESTOS MAN REMOVAL CO 1929 STATE RD.
Note:Transfer a.Name of Transporter b.Address
Stations must IPLYMOUTH 02360 1 15082245500
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 ora site to final disposal site:
Regulations 310 p ry p
CMR 19.000 JOB ROLLOFF POB 6037
a. Name of Transporter _ b.Address
CHELSEA 02150 � 6173871495
c.City/Town d.Zip Code e.Telephone Number
3.
a.Refuse Transfer Station and Owner b.Address
c.C� it /Town
d.Zip Code e.Telephone Number
4. ITURNKEY LANDFILL(WASTE MGT NH)
a.Final Disposal Site Location Name b.Final Dis osal Site Location Owner's Name
7 ROCHESTER NECK ROAD ROCHESTER
c.Final Disposal Site Address d.City/Town
NH � 03839
M e.State f.Zip Code g.Telephone Number
�o
D. Certification
o The undersigned hereby states, under the PAUL ILACQUA � PAUL ILACQUA���
'—= penalties of perjury,that he/she has read the a.Name b.Authorized Si nature
12=o Commonwealth of Massachusetts regulations for the Removal, Containment or [PRESIDENT• � 5/3/2014
c.Position/Title d. Date(mm Encapsulation of Asbestos,453 CMR 6.00 and /dd/yyyy)
310 CMR 7.15, and that the information 15082245500 JAMR CO
�o contained in this notification is true and correct e.Telephone Number f.Re resentin
to the best of his/her knowledge and belief. 929 STATE RD
o .Address
—emu_ PLYMO.UTH 02360
-Z h.City/Town i.Zip Code
anf001 ap.doc•10/02 Asbestos Notification Form•Page 3 of 3