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HomeMy WebLinkAbout0044 MAPLE AVE - HAZMAT / � U AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction#1270269 Page 1 of 4 Massachusetts Department of Environmental Protection 1100343736 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form ❑ Project Revision Project Cancellation I A. Asbestos Abatement Description 1. Facility Location: BERNARD 144 MAPLE AVE a.Name of Facility b.Street Address BARNSTABLE Iv MA 02601 000-000-0000 c.City/Town d.State e.Zip Code f.Telephone X Ix g.Facility Contact Person Name h.Facility Contact Person Title Instructions 1.All Workslte Location: IBASEMENT sections of this form must i.Building Name,Wing,Floor,Room,etc. be completed in order to comply with MassDEP 2. Is the facility occupied? FRI Yes a b.No notification requirements of 310 CMR 7.15 and 3. Is this a fee exempt notification(city,town, district, municipal housing authority, state facility, or owner- Department of Labor occupied residential property of four units or less)?o a.Yes�❑ b.No Standards(DLS) notification requirements 4. Blanket Permit Project Approval, if applicable: of 453 CMR 6.12 Approval ID# 5. Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: MassDEP Use Only Approval ID# 6.Asbestos Contractor: Date Received INEW ENGLAND SURFACE MAINTENANCE LLP 1850 WASHINGTON ST a.Name b.Address WEYMOUTH MA 02189 781-337-2117 c.City/Town d.State e.Zip Code f.Telephone C000196 h.Contract Type: ©1.Written ❑2.Verbal g.DLS License# 7. IJOSE VILLALTA S061825 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8, IRICHARD K.BOWEN MO61044 a.Name of Project Monitor b.DLS Certification# 9. IFLI ENVIRONMENTAL INC 000144 a.Name of Asbestos Analytical Lab b.DLS Certification# 10.05/14/2021 O5/14/2021 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) SAM-4 N/A c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11.What type of project is this? Fa.Demolition b.Renovation c.Repair 7 d.Other-Please Specify: 12.Abatement procedures(check all that apply): Qa.Glove Bag b.Encapsulation c.Enclosure a d.Disposal Only 7 e.Cleanup ❑� f.Full Containment Fill g.Other-Please Specify: htt ps. /•/ edep.dep.mass.gov/eDEP/WebForms/AsbestosBWPANF001.aspx 4/5/2021 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction#1270269 Page 2 of 4 13. Job is being conducted: 121a.IndoorsFE-11b.Outdoors 14 a. Total amount of each type of asbestos Containing materials(ACM)to be removed, enclosed,or encapsulated: 75 1 400 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct,Tank 40 c.Transite Pipe Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation 75 0 e.Transite Shingles 0 0 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 IVAT I 360 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15. Describe the decontamination system(s)to be used: AS REQUIRED v 16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) AS REQUIRED 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 [E-11a.Yes-1b.No project? B. Facility Description 1. Current or prior use of facility: IRESIDENCE 2. Is the facility owner-occupied residential with 4 units or less? 0 a.Yes Fill b.No 3. 1BERNARD 44 MAPLE AVE a.Facility Owner Name b.Address HYANNIS MA 02601 000-000-0000 c.City/Town d.State e.Zip Code f.Telephone 4. IX X a.Name of Facility Owner's On-Site Manager b.Address MA 00000 000-000-0000 c.City/Town d.State e.Zip Code f.Telephone 5. X a.Name of General Contractor b.Address https:Hedep.dep.mass.gov/eDEP/WebForms/AsbestosBWPANF001.aspx 4/5/2021 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction#1270269 Page 3 of 4 MA o0000 000-000-0000 c.City/Town d.State e.Zip Code f.Telephone g.Contractor's Worker's Compensation Insurer X 01/01/2022 In.Policy# i.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 11400 —� 2 a.Square Feet b.#of Floors Note:Temporary storage of Asbestos containing C. Asbestos Transportation & Disposal waste material is only allowed at the place of 1. Transporter of asbestos-containing waste material from site of generation: business of a DLS �a.Directly to Landfill or�b.To Temporary Storage Location/Transfer Station licensed Asbestos contractor or a transfer NEW ENGLAND SURFACE MAINTENANCE,LLP 850 WASHINGTON STREET station that is permitted by MassDEP and c.Name of Transporter d.Address operated in compliance WEYMOUTH MA 02189 781-337-2117 with Solid Waste e.City/Town f.State g.Zip Code h.Telephone Regulations 310 CMR 2 If a temporary storage location/transfer station is used, list name of transporter of asbestos containing 19.000 waste material from temporary storage location/transfer station to final disposal site: RED TECHNOLOGIES 110 NORTHWOOD DRIVE a.Name of Transporter b.Address BLOOMFIELD CT 06002 860-218-2428 c.City/Town d.State e.Zip Code f.Telephone 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material: RED TECHNOLOGIES 1203 PICKERING STREET a.Temporary Storage Location Name b.Address PORTLAND CT 06480 860-342-1022 c.City/Town d.State e.Zip Code f.Telephone 4. Name and location of final disposal site(asbestos landfill): MINERVA ENTERPRISES IMINERVA a.Final Disposal Site Name b.Final Disposal Site Owner Name 9000 MINERVA ROAD c.Address Note:Contractor must IWAYNESBURG OH 44688 330-866-3435 sign this form for DLS d.City/Town e.State f.Zip Code g.Telephone notification purposes D. Certification "I certify that I have personally examined IKEN FURTNEY IKEN FURTNEY the foregoing and am familiar with the 1.Name 2.Authorized Signature information contained in this document PARTNER 04/05/2021 and all attachments and that,based on my inquiry of those individuals 3.Position/Title 4.Date(MM/DD/YYYY) immediately responsible for obtaining 781-337-2117 INESM,LLP the information,I believe that the 5.Telephone 6.Representing information is true,accurate,and 850 WASHINGTON STREET EYMOUTH complete.I am aware that there are 7.Address 8.City/Town significant penalties for submitting false information,including possible fines and MA 02189 imprisonment.The undersigned hereby 9 State 10.Zip Code states that I have read the https://edep.dep.mass.gov/eDEP/WebForms/AsbestosBWPANF001.aspx 4/5/2021 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction 91270269 Page 4 of 4 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." c https:Hedep.dep.mass.gov/eDEP/WebForms/Asbestos/BWPANFOOI.aspx 4/5/2021