HomeMy WebLinkAbout2469 MEETINGHOUSE WAY/RTE 149 - Health 2469 MEETINGHOUSE WAY
West Barnstable
A = 155 - 043
i
0
r
Commonwealth of Massachusetts. c ` ■
1 00174093
Ll
Decal Number
Asbestos Notification Form ANF-001
Important: A. Asbestos Abatement De'scri tion
When fining 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?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: e/
STABLE TRAIN STATION 2469 MEETINGHOUSE WAY
a.Name of Facilit b.Street Address
BARNSTABLE
MA . 02668&ALI d.State e.,Zip Code f.Telephone Number
wsTRucrlorts 3. Worksite:Location
1.'All sections of this . . TRAIN STATION
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 NEW ENGLAND SURFACE MAINTENANCE 850 WASHINGTON STREET
Safety(DOS) a.Name b.Address
notification 1NEYMOUTH -� 02189 7.813372117
requirements of 453.
CMR 6`12 c.City/Town d.Zip Code e:Telephone Number .
f.DOS License Number g. Contract Type: El Written
®Verbal
;
h.:Facili Contact Person i:ContacYPerson's Title ; '
JOHNS BUTTS JR` ASO40209
6' a.Name of On=Site Su ervisor/Foreman b.Su ervisor/ForemamDOS CertificaLon_Number * ;
PAEVINS, < AM900334, : fro
7' a.Name of Project Monitor ,..Project Monitor,DOS Certification
ENVIROTEST LABS` AA000128
$' a.Name of Asbestos Analytical Lab, b.Asbestos Analytical Lab DOS Certification Nu6nber •
04/01/2013 04/03/2013
a:Project Start Date mm/dd/ b:End Date. mm/ddi ST
�o
8-4
�N c'Work hours Mon Fri d.Work hours Sat-Sun.,..
-o 10. a.What type of project Is this? -
�O ❑ Demolition 0 Renovation
.[2 Repair ❑Other;please-specify: b.Describe
_.
11.,1a.,Check abatement procedures: } ,
�o
,0 Glove bag [� Encapsulation _
o '❑'Enclosure a Disposal only w
El Cleanup - El.Other,.specify..,
0✓ •Full containment ,. '_ '_ b.bescnbe
�Z
=Q 12. Is the job being conducted: 0✓ Indoors? ,0 Outdoors?-.,
■ anf001ap.doc•10/02 Asbestos Notification Form-,Page 1 of 3■
Commonwealth of Massachusetts _ ■
100f74093
► 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
enca sulated:
0 [600
a.Total pipes or ducts'(linear ft) : 1 otal otner su;ac;es ,:qu:are
c.Boiler,breaching,duct,tank d.Insulating cement
surface coatings Lin.A. Sq.ft. Lin.ft., Sq:ft.
e.Corrugated or layered paper f.TroweUSprayer coatings
pipe insulation Lin.ft. Sq:ft. Lin.ft. Sq.ft.
g.Spray-on fireproofing h.Transite board,wall board
Lin.ft. Sq.ft.` Lint
is Cloths,wovenfabncs 600
Lin ft. S ft. L Other,please specify:
Lm ft:' ;So.ft.
k.Thermal solid'core pipe; _ VATIMASTIC
insulation Lin:ft: Sq ft' I.Specify
1.4. Describe the decontamination syst6iriO to be used:
AS REQUIRED
15. Describe the containerization/disposal methods to comply With 310 CMR;7 15:and 453 CMR
6.14(2) (g): :.
AS REQUIRED
16: For Emergency Asbestos Operations the DEP and:DOS officials who evaluated the emergency
a.Name of DEP Official—
Title
Title
is —
c Date mm/dd/yyy of Authorization d.DEP Waiver#
e.:Name of DOS Official:"'.. f.DOS'Official.Title
g• ( yyyy) .# ".
�N
Date mm/dd/. of Authorization ' h.'DOS Waiver
_0 17. Uo.prevailing trvage rates.as per M;G L:c: 149; §26, 27:or,27A—F.apply to this protects Yes,R✓ No
D. Facility. Description
N
—0 1. Current or prior use of facility: .
RETAIL
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes No
CAPE COD CHAPTER NRHS P.O. BOX 1912 WEST BARNSTABLE, MA
3' a.Facility Owner Name b:Address.
�o
o c:Ci /Town d.ZipCode e.Tele hone Number area:codeandektension
�� 4' a.Name of FacilityOwner's On-Site Manager b.On-Site.Manager Address
�Q c.Cityrrown d.Zip Code e.Telephone Number(area code and extension)
■ anf001ap.doc 10/02 Asbestos Notification Form•Page 2 of 3
Commonwealth of Massachusetts
10017400 :.
! Decal-Number
Asbestos Notification Form ANF-001
B. Facility Description (cont.)
5• a.Name of General Contractor' b.Address .
c.City/Town d.ZipCode e.Telephone Number area code and extension
f.Contractor's Worker's Comp.Insurer Q.Policy Number h.Ex .Date mm/dd/
6. What IS the$IZe Of tt11S facility? - a.Square Feet b.Number of floors
C. Asbestos Transportation and Disposal
1. Tran' orter:of asbestos-containing material;from site to'.temporary;storage site(if necessary)
NESM LLP
Note:Transfer a.Name of Transporter b Address
Stations must.
comply with the c.City/Town d:Zip Co.d.e e.Telephone Number
Solid Waste
Division 2. :Transporter of.asbestos-containing waste material from removal/temporary site to final disposal site:
Regulations 310
CMR MOP RED TECHNOLOGIES
a:Name of'Trans orter �, b.Address
`c."Cit /Town ` d,ZipCode e:Tele hone Number"
a Refuse Transfer Station and Owner b Address
c.Cit /Town d.ZipCode e.lele hone Number. ..
4 MINERVA ENTERPRISES;INC,,-
'r :a:FinalDis osal'Site Location Name b.Final Disposal Site Location Owner's Name
900.0:'MINERVA ROAD WAYNESBU_RG
`c.Final`Dis osal:Site Address d.Cif ITown
'
OH 44688
e.State " fc Zip Code g:_Telephone Number
�M
D. Certification
The undersigned hereby.states;under the KEN FURTNEY
�o penalties of perjury,that he/she:has read the a.Name b.Authorized Signature
�o Commonwealth.of.Massachusetts regulations 3/.191*3 :
for the:Removal,,Containment or c.Position/Title d Date mm/dd/ r
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15,and that the information
. e. Tele hone Number f.Re resentin
cont amed:in this,notification`is true and correct
o _
e to the best of his'/her knowledge and belief:.
o :'Address
ALL
�Z
'h.City/Town i.Zip Code
�Q
anf001 ap.doc•10/02 Asbestos Notification Form•Page 3 of 3