HomeMy WebLinkAbout0041 PINEWOOD AVENUE - Health VCH41inewood Rd., Hyannis
RIS GREEN PHOTOGRAPHY
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ASBESTOS MAN 11131NIOVAL (30..' IN(
t«' 929 State Road Plymouth, MA 02360
Phofl:e 508.224-5500 Fax 508-224-8883
License No,AC00342
Mr. Thomas McKean
Barnstable Health Department
200 Main Street
Hyannis, MA 02601
Dear Mr. McKean:
We are notifying you about an.asbestos removal job to be done
at
. The start up
date is U S
and the end date is 5
y
Enclosed please find a copy of the Asbestos Notification Form
for.your files. (ANF-001)
If you have any questions, please contact us at (508) 224-5500.
Sincerely,
Paul Ilacqua i
Enc: ANF-001 form
t , .
Commonwealth of Massachusetts ■
100135605
Decal Number
I, Asbestos Notification Form ANF-001
Important:When filling out A. Asbestos Abatement Description
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? 0 Yes ❑ No
to move your
cursor-do not b. Provide blanket decal number if applicable: Blanket Decal Number
use the return
key. 2. Facility Location:
TOM GREENE 41 PINEWOOD AVE
a.Name of Facility b.Street Address
HYANNIS MA 02601 J 5087759197
_ c.City/Town d.State e.Zip Code f.Telephone Number
INSTRUCTIONS 3. Worksite Location:
1.All sections of this RESIDENCE 12ND IATTIC
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? 0 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
requirements of 453 PLYMOUTH � � 02360 1 15082245500
CMR 6.12 c.City/Town d.Zip Code e.Telephone Number
AC000342
f.DOS License Number g. Contract Type: ❑Written 0 Verbal
h.Facility Contact Person i.Contact Person's Title
PAUL A ILACQUA I JAS050350
6' a.Name of On-Site Supervisor/Foreman b.Su ervisor/Foreman DOS Certification Number
7' ASBESTOS CONSULTANTS JAM051114
a.Name of Project Monitor b.Pro ect Monitor DOS Certification Number
ASBESTOS CONSULTANTS AA000173
$' a.Name of Asbestos Anal ical Lab b.Asbestos Analytical Lab DOS Certification Number
9. 10/15/2011 10/15/2011
�ogro'ect Start Date mmlddl b.End Date mmldd/
�0 M-2PM I 17AM-2PM
�N c.Work hours Mon-Fri. d.Work hours Sat-Sun.
=0 10. a. What type of project is this?
=0 ❑ Demolition 0 Renovation
❑ Repair ❑ Other, please specify: b.Describe
11. a. Check abatement procedures:
_0 ❑Glove bag ❑ Encapsulation
o ❑ Enclosure ❑ Disposal only
❑ Cleanup ❑ Other, specify:
0 Full containment b. Describe
z
=Q 12. Is the job being conducted: ❑✓ Indoors? ❑Outdoors?
■ anf001ap.doc•10/02 Asbestos Notification Form•Page 1 of 3 ■
f Commonwealth of Massachusetts ■
100135605
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:
101 1200 ��
a.Total pipes or ducts(linear ) b. oTTai other su aces square 11)
c.Boiler,breaching,duct,tank d.Insulating cement
surface coatings Lin.ft. Sq.ft. Lin.ft. Sq.ft.
e.Corrugated or layered paper f.Trowel/Sprayer coatings I
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.
i.Cloths,woven fabrics j Other,please specify: 200
Lin.ft. S .ft. Lin.ft. S .ft.
k.Thermal,solid core pipe U VERMICULITE
insulation Lin.ft. Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used:
REMOVE ASBESTOS IN FULL CONTAINMENT UNDER NEGATIVE AIR PRESSURE
15. 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 AND LABELED BAGS
16. For Emergency Asbestos Operations, the 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#
e.Name of DOS Official f.DOS Official Title
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 0✓ No
�o
B. Facility Description j
N
�o 1. Current or prior use of facility: RESIDENCE
—0 2. Is the facility owner-occupied residential with 4 units or less? ❑✓ Yes ❑ No
TOM GREENE 41 PINEWOOD AVE
3' a.Facility Owner Name b.Address
0 H NNIS 1 15087759197
o a Cit /Town d.Zip Code e.Tel hone Number area code and extension)
�LL 4.
Z a.Name of Facility Owner's On-Site Manager b.On-Site Mana er Address
�Q c.City/Town d.Zip Code e.Telephone Number(area code and extension)
■ anf001ap.doc•10/02 Asbestos Notification Form•Page 2 of 3■
�e
Commonwealth of Massachusetts IN
100135605
Asbestos Notification Form ANF-001 Decal Number
B. Facility Description (cont.)
5' a.Name of General Contractor b.Address
c.City/Town d.Zip Code (ee..Telephone Number(area code and extension)
f.Contractor's Worker's Comp.Insurer q.Policy Number h.Exp.Date mm/dd/ m
6. What is the size of this facility? 2000 1 12
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 929 STATE RD
Note:Transfer a.Name of Transporter b.Address
Stations must JPLYMOUTH 023601 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 site to final disposal site:
Regulations 310
CMR 19.000 JOB ROLL )FF POB 6037
a.Name of Transporter b.Address
CHELSEA 16173871595
c.Cit /Town d.Zip Code e.Telephone Number
3.
a.Refuse Transfer Station and Owner b.Address
c.Cit /Town d.Zip Code e.Telephone Number
4. ITURNKEY LANDFILL(WASTE MGT NH)
a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name
7 ROCHESTER NECK ROAD IROCHESTER
c.Final Disposal Site Address d.Cit !Town
NH —� 03839
�cr) e.State f.Zip Code g.Telephone Number
�o
D. Certification
�N
The undersigned hereby states, under the PAUL ILACQUA PAUL ILACQUA
�° penalties of perjury,that he/she has read the a.Name _ b.Authorized Signature
�o Commonwealth of Massachusetts regulations PRESIDENT �� 10/3/2011
for the Removal, Containment or
Encapsulation of Asbestos,453 CM c.Position/Title d.Date mm/dd/ rR 6.00 and 15082245500 _� AMR CO
310 CMR 7.15, 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. 929 STATE RD
o g.Address _
_U_ PLYMOUTH 02360
Z h.City/Town i.Zip Code
�Q
anf001ap.doc•10/02 Asbestos Notification Form•Page 3 of 3
TOXIC AND HAZARDOUS MATERIALS WGISTRATION FORM
Mail To:
NAME OF BUSINESS: 0-�0t G -� ��o`��- "Y Board of Health
MAILING ADDRESS: qk t"jc-WeLQ `o yotJ6 Town of Barnstable
TELEPHONE NUMBER: �J4g_ �� 4 tF$ P.O. Box 534
CONTACT PERSON: Hyannis, MA 02601
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in gbantities tot (ling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous
characteristics and must be registered `�W
iiii Nil
In 1
Please put a check beside each product that you store "
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Household cleansers, oven cleaners
White Copy-Health Department/ Canary Copy-Business
� L
4 i TOWN OF BARNSTABLE
LOCATION. l I/�- �% ;ter J dc;� SEWAGE # "� 3
n
VILLAG -,4, / s. ASSESSOR'S MAP & LOT
F
INSTALLER'S NAME&PHONE N0.- l�a��^-s .— 7S-"� ? L
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) .S Jam'"'s-O� i~ �' (size)�,�• W =—,r�
NO.OF BEDROOMS t
BUILDER OR OWNER_<�/�ct Z-�--
PERMITDATE:� COMPLIANCE DATE4;�"s/4
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility Feet
Edge of Wetland and Leaching Facility(If anyrwetlands exist
within 3,00 feet of leaching facility) Feet
Furnished by
71 -T
F
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T0VFN Or BAIUNST B E Cam`
vr�A'IZON � �' i' u� f t - C SEWAGE #
T .1
92MUVILLAGE 6 �i« �� / s" ASSESSOR'S MAI & LOT
INSTALLER'S NAME 8c PHONE NO.
SEPTIC TANK CAPACITY ��SG
LEACHING FACILITY: (type) .S 7 'd L_ (size) / !AZ
NO,OF BEDROOMS t
BUILDER OR OWNERS
G-- c� c <
PERMIT DATE: -COMPLIANCE DATES -- .
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (/any wells exist
on site or within 200 feet of leaching facility)/ Feet
Edge of Wetland and Leaching Facility(Il`�.y�wetlands exist
within 300 feet of leaching facility) Feet.
Furnished by
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(op 433
No.
/ Fee 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprieation for Zigogal 6pgtem Construction Permit
Application for a Permit to Construct( )Repair iX )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
4.1 Pinewood. Rd.. , Hyannis Thomas & Gwen Green
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 Septic system— consisting
of a tank, D-box and. 3 leach chambers with stone all around..
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the vironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu by t ' o o�tUjealth�. ,-1
_
Signe Lb Date
Application Approved byum Date
Application Disapproved for the following real
Permit No. 1 Date Issued
1 > �
No. Fee $5 0 oe
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓/
Yes
- . PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
x 0(pprication for Migoal *p9tem Construction Permit
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
4-1 Pinewood. Rd.. , Hyannis Thomas & Gwen Green
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
" Wm. E Robinson Septic Service
- P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan_ Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand.
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system— consist in{r"r t
of.,.a tank, D-box and 3 lea'bh chambers with stone all around..
+t
Date last inspected: i
Agreement: i {
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with'the_provisions of Title 5 of the vironmental Code and not'to place the system in operation until a Certifi-
cate of Compliance has been issu by t ' o of LIealth. / }
Signe � t t Date
Application Approved byn�m Date
Application Disappro'ved,for the following reas is
Permit No. 1 i I Date Issued
- ----------' ------ --- -- -------
i THE COMMONWEALTH OF MASSACHUSETTS
Green BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( )
Abandoned( )by Wm. E, Robinson Septic Service
at 41 Pinewood. Rd. , Hyannis It ads ben constructed in accordance
with the ppr-ovisions of Title 5 and the for Disposal System Construction Permit No. �/ dated
Installer . E .. Robinson on Sr. Designer o n
The issuance of this ermit shal not be construed as a guarantee that th s stem will function as desiMv
P �Ag Y �Date i /l � l� Inspector+ �/� f 1� �� *J��ll, `'"
Y"
--------�- --------------------------- C -
No. E 2 Fee $5 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
lwigogai *pgtem Con%truction Permit
Permission is hereby anted to Construct( )Repair(X)Upgrade( )Abandon( )
System located at 41 Pinewood Rd . , Hyannis
and as described in the above Application for Disposal System Construction Permit. The applicant recognises his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Con tructi use a com eted within three years of the date of e t._ f r
Date: 0 Approved by
r
116199
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, William E . Robinson,SAereby certify that the application for disposal works
construction permit signed by me dated ,/ ����''� , concerning the
property located at 41 Pinewood. Rd.. , H Vann i s meets all of the
following criteria:
i
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and th percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 fe of the proposed septic system
There are no private wells within 50 feet of the proposed septic system
• There is no increase in flow or change in use proposed
• There are no variances re ested or needed.
• The bottom of the pro sed leaching facility will not be located less than five feet above the
maximw I adjusted oundwater table elevation. [Adjust the groundwater table using the Frimptor
method when appl' blel
• If the S.A.S. ' 1 be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching fac' ity will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
MAXB) G.W.Elevation +the High G.W. Adjustment
DIFFERENCE.BETWEEN A and B �
SIGNED : z�
C� l 1 z DATE:
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[Sketch proposed plan of system on back].
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