HomeMy WebLinkAbout0066 SALTEN POINT ROAD - Health 66 Salten Point
arnstable
A= 280-026
Commonwealth of Massachusetts 100209531
Asbestos.Notification Form ANF-001
Asbestos Project#
' Project Revision
Project Cancellation
A;=Asbestos Abatement Description
1.Facility Location:
ELIZABETH WHEELER 66 SALTEN POINT"RD
Name of Facility Street Address
Instructions 1.All BARNSTABLE MA 02601 5083626557
sections of this form City/Town State Zip Code Telephone
must be completed in SAME OWNER
order to comply with
MassDEP notification Facility Contact.Person Name Facility Contact Person Title
requirements of 310 Worksite Location: RESIDENCE
CMR 7.15 and
Department of Labor Building Name,Wing,Floor,Room,etc.
Standards(DLS) 2• Is the facility occupied? r'Yes r No
notification
requirements of 453
CMR6.12 3. Is this'a fee exempit'lnotifidation (city,town, district, municipal housing authority, state facility, or
owner-occupied residential property of four units or less)? F" Yes C No
MassDEP Use Only 4.Blanket Permit Project Approval,if applicable:
Approval ID#
Date Received
5.Non-Traditional Asbestos Abatement Work Practice Approval,
if applicable: Approval ID#
2.Submit Original
Form To:
Commonwealth of 6.Asbestos Contractor
Massachusetts ASBESTOS MAN REMOVAL : 929 STATE ROAD
Asbestos Program
P.O.Box 120087 ;Name Address
Boston,MA 02112- PLYMOUTH MA 02360 5082245500
0087
City/Town `State Zip Code Telephone
AC000342 Contract Type: r Written F Verbal
10 DL License#
7• J91N BERTON AS002057
cE a Na e'of Contractor's Qn-Site Sup
ervis�7rlForeman DLS Certification#
8• El MN G.MORGAN JR. AM051114
N TCOZgf Project Monitor DLS Certification#
C14
is 9• G ®R. N&ELIKERTON AA000173
Na°maof Asbestos Analytical Lab DLS Certification#
10. 1 8/2014 10/28/2014
[� c� Project Start Date(MM/DD/YYYY) End Date(MM/DD/YYYY)
= 7AM-3PM 7AM-3PM
Work Hours-Monday Through Friday Work Hours-Saturday&Sunday
11. What type of project is this?
I- Demolition IT Renovation [ Repair r Other-Please Specify:
Revised: l 11131..2013 Page 1 of 4
Commonwealth of Massachusetts
w 100209531
Asbestos Notification Form ANF-001
on Asbestos Project#
r Project Revision
r Project Cancellation
A.Asbestos Abatement Description: (cont.)
12.Abatement procedures(check all that apply):
r Glove Bag r Encapsulation r Enclosure r Disposal Only [" Cleanup ( ; Full Containment
(— Other-Please Specify:
13.Job is being conducted: r; Indoors [" Outdoors
14.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:.
800
Linear Feet(Lin.Ft.) Square Feet(Sq.Ft.)
Boiler,Breaching,Duct, Transite Pipe
Tank Surface Coatings Lin.Ft. Sq.Ft. Lin.Ft. Sq.Ft.
Pipe Insulation Transite Shingles
Lin.Ft. ;Sq.Ff. Lin.Ft. Sq.Ft.
Spray-On Fireproofing Transite Panels
Lin.Ft. Sq.Ft. Lin.Ft. Sq.Ft.
Cloths, Woven Fabrics Other-Please Specify:
Lin.Ft. Sq.Ft.
Insulating Cement VAT 800
Lin.Ft. Sq.Ft. Lin.Ft. Sq.Ft. -
15.Describe the decontamination system(s)to.be used:-
REMOVEASBESTOS IN FULL CONTAINMENT UNDER NEGATICEAIR PRESSURE
16.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
Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency:
17.ForEmergency p ,
Name of MassDEP Official Title of MassDEP Official
Date of Authorization(MM/DD/YYYY) Waiver#
Name.of DLS Official Title of DLS Official .
Date of Authorization(MM/DD/YYYY) Waiver#
18.Do prevailing wage rates as per M.G.L.c. 149, §26,27 or 27A—F apply to this r yes [✓ No
project?
Revised: 11/13/2013 Page 2 of
Commonwealth of Massachusetts
00209531
Asbestos Notification Form ANF-001 Asbestos Project#
�Y..
q e F-, Project Revision
1 ( Project Cancellation
B. Facility Description
1.Current or prior use of facility: RESIDENCE
2.Is the facility owner-occupied residential with 4 units or less? F Yes r_7 No
3,SAME AS ABOVE SAME
Facility Owner Name Address
SAME MA 02630 5083626557
City/Town State Zip Code Telephone
4.NONE N/A
Name of Facility Owner's On-Site Manager Address
N/A MA 02630 5083626557
City/Town State Zip Code Telephone
5 NONE N/A
Name of General Contractor Address
N/A MA 02630 5083626557
City/Town State `'Zip Code_, Telephone
Note:Temporary N/A
storage of Asbestos Contractor's Worker's Compensation Insurer
containing waste 9/y/9999
material is only 99999999999999999999999999999999
allowed at the place Policy# - Expiration Date(MM/DD/YYYY)
of business of a DLS
licensed Asbestos 6.What is the size of this facility? 2000 2
contractor or a transfer
station that is
permitted by Square Feet #of Floors
MassDEP and C. Asbestos Transportation.& Disposal
operated in
compliance with Solid
Waste Regulations 1.Transporter of asbestos-containing waste material from site of generation:
310 CMR 19.000
r Directly to Landfill or 1✓ To Temporary Storage Location/Transfer Station
ASBESTOS MAN REMOVAL CO 929 STATE RD
Name of Transporter Address
PLYMOUTH MA 02360 5082245500
City/Town State Zip Code Telephone
2.If a temporary storage location/transfer station is used; list name of transporter of asbestos containing
waste material from temporary storage location/transfer station to final disposal site:
JOB ROLLOFF- POB 6037
Name of Transporter Address
CHELSEA MA 02150 6173871495
City/Town State Zip Code Telephone
Revised: 11/13/2013 Page 3 of 4
'Ll �
Commonwealth of Massachusetts Asbestos Notification Form ANF-001Asbestos Project#
(- Project Revision
r" Project Cancellation
note:Uomractor must C.Asbestos Transportation&Disposal: (cont.)
sign this form for DLS
notification purposes 3.Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
ASBESTOS MAN REMOVAL CO 25 ADAMS ST.
Temporary Storage Location Name Address
BRAINTREE MA 02184 5082245500
City/Town State Zip Code Telephone
4.Name and location of final disposal site(asbestos landfill):
TURNKEY LANDFILL WASTE MGT. WASTE MGT.
Final Disposal Site Name Final Disposal Site Owner Name
90 ROCHESTER NECK RD
Address
ROCHESTER MA 03839 6033390039 `
City/Town ' $tale .'Zip Code Telephone
D. Certification .
"I certify that I have personally
examined the foregoing and am PAUL ILACOUA PAUL ILACOUA
familiar with the information Name Authorized Signature
contained in this document and PRESIDENT 10/15/2014
all attachments and that,based Position/Title Date(MM/DD/YYYY)
on my inquiry of those 5082245500 AMR CO
individuals immediately
responsible.for obtaining the Telephone Representing
information,I believe that the _ 929 STATE RD PLYMOUTH
information is true,accurate,and Address City/Town
complete. I am aware that there MA 02360
are significant penalties for .
submitting false information, State Zip Code
including possible fines and
imprisonment.The undersigned
hereby states that I have read the
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."
I
Revised: 11/13/2013 Page 4 of 4