7.5 LYME STREET - ASBESTOS Massachusetts Department of Environmental Protection 100434861
BWP AQ 04 (ANF-001) Asbestos Project#
L
Asbestos Notification Form
r" Project Revision
7 r Project Cancellation
A. Asbestos Abatement Description
1.Facility Location:
7.5 LYME ST.LLC 7.5 LYME ST
Instructions 1.All a.Name of Facility b.Street Address
sections of this form SALEM MA 01970 0000000000
must be completed in
order to comply with c.Citylrown d.State e.Zip Code f.Telephone
MassDEP notification N/A N/A
requirements of 310
CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title
Department of Labor Worksite Location: SIDING
Standards(DLS) i.Building Name,Wing,Floor,Room,etc.
notification
requirements of 453 2. Is the facility occupied? r a.Yes r b.No
CMR 6.12
3. Is this a fee exempt notification(city,town, district, municipal housing authority, state facility, or
owner-occupied residential property of four units or less)? r a.Yes r b.No
MassDEP Use Only
4.Blanket Permit Project Approval,if applicable:
Date Received Approval ID#
5.Non-Traditional Asbestos Abatement Work Practice Approval,
if applicable: Approval ID#
6.Asbestos Contractor:
ALL STATE ENVIRONMENTAL INC 94 BEAVER AVE
a.Name b.Address
LYNNFIELD MA 01940 7813344647
c.Citylrown d.State e.Zip Code f.Telephone
AC000199 h.Contract Type: r 1.Written r 2.Verbal
g.DLS License#
7. EDWARDJOHNSON AS033642
a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification#
8 OLGA VOYTAZH AM900523
a.Name of Project Monitor b.DLS Certification#
9 ACA ENVIRONMENTAL LAB LLC AA000261
a.Name of Asbestos Analytical Lab b.DLS Certification#
10.
10/24/2025 10/30/2025
a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYY`/)
7AM-4PM N/A
c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday
11.What type of project is this?
I— a.Demolition R b.Renovation r c.Repair r d.Other-Please Specify:
Revised: 11/13/2013 Page 1 of 4
Massachusetts Department of Environmental Protection 1100434861
BWP AQ 04 (ANF-001) Asbestos Project#
Asbestos Notification Form
17.. Project Revision
r Project Cancellation
A.Asbestos Abatement Description: (cont.)
12.Abatement procedures(check all that apply):
r a.Glove Bag r b.Encapsulation r c.Enclosure r d.Disposal Only r e.Cleanup
r f.Full Containment r g.Other-Please Specify:
13.Job is being conducted: r a.Indoors r b.Outdoors
14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:
0 120
1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft)
b.Boiler,Breaching,Duct, c.Transite Pipe
Tank Surface Coatings 1.Lin.Ft 2.Sq.Ft 1.Lin.Ft 2.Sq.Ft
d.Pipe Insulation e.Transite Shingles
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 SIDING 120
1.Lin.Ft 2.Sq.Ft. 1.Lin.Ft 2.Sq.Ft.
15.Describe the decontamination system(s)to be used:
SMALL D/CON
16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g):
2 6MIL BAGS
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 r a.Yes 17 b.No
project?
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`7JMassachusetts Department of Environmental Protection 100434861
BWP AQ 04 (ANF-001) Asbestos Project#
Asbestos Notification Form r Project Revision
r Project Cancellation
B. Facility Description
LIVING
1.Current or prior use of facility:
2.Is the facility owner-occupied residential with 4 units or less? r a.Yes r: b.No
3
SAME SAME
a.Facility Owner Name b.Address
SALEM MA 01970 0000000000
c.Cityffown d.State e.Zip Code f.Telephone
4.N/A N/A
a.Name of Facility Owner's On-Site Manager b.Address
N/A MA 00000 0000000000
C.City/Town d.State e.Zip Code f.Telephone
N/A N/A
5 a.Name of General Contractor b.Address
N/A MA 00000 0000000000
c.Citylrown d.State e.Zip Code f.Telephone
ST.PAUL THE TRAVELER'S
g.Contractor's Worker's Compensation Insurer
7PJUB9F457917 2/26/2026
h.Policy# i.Expiration Date(MM/DD/YYYY)
600 2
6.What is the size of this facility? -
a.Square Feet b.#of Floors
Note:Temporary storage of Asbestos C. Asbestos Transportation & Disposal
containing waste 1.Transporter of asbestos-containing waste material from site of generation:
material is only
allowed at the place r. a.Directly to Landfill or W b.To Temporary Storage Location/Transfer Station
of business of a DLS
licensed Asbestos
contractor or a transfer AEI P.O.BOX 1431
station that is c.Name of Transporter d.Address
permitted by
MassDEP and WAKEFIELD MA 01880 7817607593
operated in e.City/Town f.State g.Zip Code h.Telephone
compliance with Solid
Waste Regulations
310 CMR 19.000 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:
J.O.B ROLLOFF INC BOX 6037
a.Name of Transporter b.Address
CHELSEA MA 02150 6173871495
c.Citylrown d.State e.Zip Code f.Telephone
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Massachusetts Department of Environmental Protection 100434861
BWP AQ 04 (ANF-001)
Asbestos Notification Form Asbestos Project#
r' Project Revision
r Project Cancellation
C.Asbestos Transportation&Disposal:(cont.)
3.Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
J.O.B.ROLLOFF INC BOX 6037
a.Temporary Storage Location Name b.Address
CHELSEA MA 02150 6173871495
c.City/Town d.State e.Zip Code f.Telephone
4.Name and location of final disposal site(asbestos landfill):
WASTE SYSTEMS MANAGEMENT N/A
a.Final Disposal Site Name b.Final Disposal Site Owner Name
90 ROCHESTER RD.
c.Address
ROCHESTER Ni 00000 0000000000
d.City/Town e.State f.Zip Code g.Telephone
Note:Contractor must
sign this form for DLS
notification purposes A Certification
EDWARDJOHNSON EDWARDJOHNSON
"I certify that I have personally 1.Name 2.Authorized Signature
examined the foregoing and am MANAGER 10/14/2025
familiar with the information
3.Pos
contained in this document and fionlfitle 4.Date(MM/DD/YYYI�
all attachments and that, based 7817607593 AEI
on my inquiry of those 5.Telephone 6.Representing
individuals immediately P.O.BOX 1431 WAKEFIELD
responsible for obtaining the 7.Address 8.Cityrrown
information,I believe that the MA 01880
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."
Revised: 11/13/2013 Page 4 of 4