10 GRANT ROAD - ASBESTOS Massachusetts Department of Environmental Protection 100398897
BWP AQ 04 (AN F-001) RECEIVED JAN 0� `F�O�rt Asbestos Project#
Asbestos Notification Form Project Revision
Project Cancellation
CITY OF SALEM
A. Asbestos Abatement Descript o°n°OFHEALTH
1. Facility Location:
MARNIK _ 10 GRANT ROAD
a.Name of Facility b.Street Address
SALE"M 4' MA 01970 000-000-0000
c.City/Town d.State e.Zip Code f.Telephone
X X
g.Facility Contact Person Name h.Facility Contact Person Title
Instructions 1.All WorkSlte Location: BASEMENT
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? a.Yes 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)?: a.Yes b.No
Standards(DLS)
notification requirements 4. Blanket Permit Project Approval, if applicable: C
of 453 CMR 6.12 Approval ID#
5. Non-Traditional Asbestos Abatement Work Practice Approval, if applicable:
Approval ID#
MassDEP Use Only
6.Asbestos Contractor:
Date Received NEW ENGLAND SURFACE MAINTENANCE LLP 850 WASHINGTON ST
a.Name b.Address
WEYMOUTH MA 02189 781-337-2117
c.City/Town d.State e.Zip Code f.Telephone
1AC000196 h.Contract Type: 1.Writta 2.Verbal
g.DLS License#
7. 1 ELMER E,PINEDA AS001291
a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification#
8. 1 FRANK N.BALAGTAS i 'AM000091 I
a.Name of Project Monitor b.DLS Certification#
9. IFLI ENVIRONMENTAL INC IAA000144 i
a.Name of Asbestos Analytical Lab b.DLS Certification#
10. 01/02/2024 1 101/02/2024
a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY)
7AM-3 N/A
c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday
11.What type of project is this?
ra.Demolition b.Renovation c.Repair d.Other-Please Specify: ,
12.Abatement procedures (check all that apply):
�a.Glove Bag b.Encapsulation nc.Enclosure d.Disposal Only ne.Cleanup f.Full Containment
g.Other-Please Specify:
13. Job is being conducted: a.Indoors 1-1 b.Outdoors
14 a.Total amount of each type of asbestos Containing materials (ACM)to be removed, enclosed, or
encapsulated:
'15
1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.)
b.Boiler,Breaching,Duct,Tank � c.Transite Pipe
Surface Coatinqs 1 1 in Pt Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. -�
d.Pipe Insulation 15 e.Transite Shingles
1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
f.Spray-On Fireproofing � 9.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
1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
15. Describe the decontamination system(s)to be used:
AS REQUIRED
16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g):
AS REQUIRED
17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the
emergency:
IJOHANNAH CRONIN INSPECTOR
a.Name of MassDEP Official b.Title of MassDEP Official
2/28/2023 1 1NAW 231-2125
c.Date of Authorization(MM/DD/YYYY) d.Waiver#
OP:LINE I IONLINE J
e.Name of DLS Official f.Title of DLS Official
12/28/2023 40438-2023
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 �1 a.Yes U b.No
project?
B. Facility Description
1. Current or prior use of facility: RESIDENCE
2. Is the facility owner-occupied residential with 4 units or less? a.Yes b.No
3. MARNIK 10 GRANT ROAD
a.Facility Owner Name b.Address
SALEM MA 01970 000-000-0000
c.City/Town d.State e.Zip Code f.Telephone
4. X Y
a.Name of Facility Owner's On-Site Manager b.Address
Note:Temporary storage Ix MA 00000 000-000-0000
of Asbestos containing B. X �iIX
waste material is only
a.Name of General Contractor b.Address
allowed at the place of
business of a DLS X MA 00000 000-000-0000
licensed Asbestos c.City/Town d.State e.Zip Code f.Telephone
contractor or a transfer X
station that is permitted g.Contractor's Worker's Compensation Insurer
by MassDEP and X _ 01/01/2025
i
operated in compliance h.Policy# i.Expiration Date(MM/DD/YYYY)
with Solid Waste
Regulations 310 CMR 6. What is the size of this facility? 1400 j2
19.000
a.Square Feet b.#of Floors
C. Asbestos Transportation & Disposal
1.Transporter of asbestos-containing waste material from site of generation:
a.Directly to Landfill or 1 b.To Temporary Storage Location/Transfer Station
NEW ENGLAND SURFACEI MAINTENANCE,LLP 1850 WASHINGTON STREET i
c.Name of Transporter d.Address
WEYMOUTH I MA 102189 781-337-2117
e.City/Town f.State g.Zip Code h.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:
RED TECHNOLOGIES I 1173 PICKERING STREET
a.Name of Transporter b.Address
IPORTLAND —� CT 06480 860-342-1022
c.CityTTown d.State e.Zip Code f.Telephone
Note:Contractor must
sign this form for DLS 3. Name and address of temporary storage location/transfer station for the asbestos containing waste
notification purposes material:
i RED TECHNOLOGIES 1 173 PICKERING STREET
PORTLAND GT 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 ,MINERVA
a.Final Disposal Site Name b.Final Disposal Site Owner Name
[8955 MINERVA ROAD
c.Address
WAYNESBURG OH 44688 1330-866-3435
d.City/Town e.State f.Zip Code g.Telephone
D. Certification _
"I certify that I have personally examined JIM DOYLE i JIM DOYLE J
the foregoing and am familiar with the 1.Name 2.Authorized Signature
information contained in this document PARTNER 12/28/2023
and all attachments and that,based on
3.Position/Title 4.Date(MM/DD/YYYY)
my inquiry of those individuals
immediately responsible for obtaining 781-337-2117 NESM,LLP
the information,I believe that the 5.Telephone 6.Representing
information is true,accurate,and 85 WWASHINGTON STREET ] [WEYMOUTH
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
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."