18 WILLOW AVENUE - ASBESTOS (2) Massachusetts Department of Environmfi�,l�r�Y�c�n
BWP AQ 04 (ANF-001) t C�W CV Asbestos
P of
Asbestos Project#
Project Revision Notification JAN 3 0 2025 V Project Revision
W Project Cancellation
CITY OF SALEM
A. Asbestos Abatement Description
1.Facility Location:
MOSKAL 18 WILLOW AVE
Instructions 1.All a.Name of Facility b.Street Address
sections of this form SALEM
must be completed in _ MA 01970 0000000000
order to comply with c.City/Town d.State e.Zip Code f.Telephone
MassDEP notification X X
requirements of 310
CMR 7.15 and g•Facility Contact Person Name h.Facility Contact Person Title
Department of Labor Worksite Location: ATTIC
Standards(DLS)
notification i.Building Name,Wing,Floor,Room,etc.
requirements of 453 2.Blanket Permit Project Approval,if applicable:
CMR 6.12 Approval ID#
3.Non-Traditional Asbestos Abatement Work Practice Approval,
MassDEP Use Only if applicable: Approval ID#
Date Received 2/10/2025 2/11/2025
a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY)
7-3 N/A
c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday
B. Other Project Revisions:
Note:Temporary
storage of Asbestos
containing waste
material is only
allowed at the place
of business of a DLS
licensed Asbestos
contractor or a transfer
station that is
permitted by
MassDEP and
operated in
compliance with Solid
Waste Regulations
310 CMR 19.000
Note:Contractor must
sign this form for DLS
`71 Massachusetts Department of Environmental Protection 100420294R1
BWP AQ 04 (ANF-001) Asbestos Project#
Project Revision Notification
� Fe Project Revision
rv—# Project Cancellation
C. Certification
KEN FURTNEY KEN FURTNEY
"I certify that I have personally 1.Name 2.Authorized Signature
examined the foregoing and am PARTNER 1/28/2025
familiar with the information
3.Position/Title 4.Date(MM/DD/YYYY)
contained in this document and
all attachments and that, based 7813372117 NESM,LLP
on my inquiry of those 5.Telephone 6.Representing
individuals immediately 850 WASHINGTON STREET WEYMOUTH
responsible for obtaining the 7.Address 8.City/Town
information, I believe that the MA 02189
information is true, accurate, and
complete. I am aware that there 9•State 10.Zip Code
are significant penalties for
submitting false information,
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."
Ra•iica�l 1 1/1 2/7/11 Panes 7 of 7