Asbestos Abatement Unit N512 4-2-18 DEGTAM RE-CEIVED
ENVIRONMENTAL SERVICES
APR 0 52013
April 2, 2018 CITY OF SALEM
BOARD OF HEALTH
Salem Board of Health Agent
120 Washington Street, 4` Fl.
Salem, Ma. 01970
Re: Peauot Hi¢hlands-10-12 First Street- North Unit 512
Dear Sir/Madam:
Please be advised that Dec-Tam Corporation is performing an asbestos abatement project at the
above referenced location. This work is scheduled for April 12, 2018.
All applicable local, state and federal agencies have been notified of this work.
Please let me know if you have any questions.
Sincerest regards,
Jiro, WXW:n 6
Sean Clements
Sales Estimator
SC/nap
Enclosure
50 Concord Street,North Reading,MA 01864 • P:978.470.2860 F:978.470.1017 • www.dectam.com
Massachusetts Department of Environmental Protection - —
j BWP AQ 04 (ANF-001) 1100283576
Asbestos Project#
i Asbestos Notification Form Project Revision
LLi*
, r Project Cancellation
A. Asbestos Abatement Description
1.Facility Location:
PEQUOT HIGHLANDS 10-12 FIRST STREET
Instructions 1.All a.Name of Facility b.Street Address
sections of this form SALEM
must be completed in MA 01970 2077809800
order to comply with C.City/rown d.State e.Zip Code f.Telephone
MassDEP notification CHRISTOPHERPOULIN MANAGEMENT
requirements of 310
CMR 7.15 and 9.Facility Contact Person Name h.Facility Contact Person Title
Department of Labor Worksite Location: NORTH UNIT512
Standards(DLS)
notification 1.Building Name,Wing,Floor,Room,etc.
requirements of 453 2. Is the facility occupied? r a.Yes I-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)? )° a.Yes W b. No
MassDEP Use Only
4.Blanket Permit Project Approval,if applicable:
Date Received Approval ID#
5.Non-Traditional Asbestos Abatement Work Practice Approval,
2.Submit Original if applicable: Approval ID#
Form To:
Commonwealth of
Massachusetts 6. Asbestos Contractor:
P.O.Box 4062
Boston,MA 02211 DEC-TAMCORPORAT10N 5000NCORDST
a.Name b.Address
NORTH READING MA 01864 9784702860
c.City/Town d.State e.Zip Code f.Telephone
AC000036 h.Contract Type: r 1.Written r 2.Verbal
g.DLS License#
? GEORGEA PAGE AS071933
a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# i
8. BRIANA PICCOLO AM041519
a.Name of Project Monitor b.DLS Certification#
9 BOCK&CLARK ENVIRONMENTAL,LLC AA000227
a.Name of Asbestos Analytical Lab b.DLS Certification#
10.
4/12/2018 4/12/2018
a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY)
8AM4.30PM N/A
c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday
11.What type of project is this?
f a Demolition p' b.Renovation IF c.Repair I— d.Other-Please Specify:
Revised: 11/13/2013 l 8
O r Sa Pagel of4
Massachusetts Department of Enviromnental Protection 100283576
BWP AQ 04 (ANF-001)
Asbestos Project#
Asbestos Notification Form r Project Revision
F- Project Cancellation
A.Asbestos Abatement Description: (cont.)
12.Abatement procedures(check all that apply):
t-_ a.Glove Bag F b.Encapsulation V, c. Enclosure F d.Disposal Only i e. Cleanup
t- f.Full Containment r, g. Other-Please Specify:
13.Job is being conducted: P a.Indoors ii- b. Outdoors
14 a. Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:
25
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 PARQUET FLOOR&MASTIC 25
1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
15.Describe the decontamination system(s)to be used:
THREE CHAMBERED DECONTAMINATION SYSTEM
16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g):
MATERIAL WILL BE WETTED,WRAPPED AND LABELLED FOR DISPOSAL
17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency:
a.Name of MassDEP Official b.Title of Mas DEP Official
c.Date of Authorization(MM/DD/Y(YY) d.Waiver#
e.Name of DLS Official f.Title of DLS Official
9.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 P b..No
project?
Revised: 11/13/2013 Page 2 of 4
I
Massachusetts Department of Environmental Protection - - - -
BWP AQ 04 (ANF-001) I00283576
Asbestos Notification Form Asbestos Project#
F Project Revision
1- Project Cancellation
B. Facility Description
1.Current or prior use of facility: HOUSING
2. Is the facility owner-occupied residential with 4 units or less? a.Yes r b.No
3 PEQUOTSALEM LIMITED PARTNERSHIP CORP. 33 SILVER STREET SURE 200
a.Facility Owner Name b.Address
PORTLAND ME 04101 2077819800
c.City/Town d.State e.Zip Code f.Telephone
4 CHRISTOPHER PODUN 10-12 FIRST STREET
a.Name of Facility Owner's On-Site Manager b.Address
SALEM MA 01970 2077809800
c.City/Town d.State e Zip Code f.Telephone
5 DEC-TAM CORPORATION 50 CONCORD STREET
a.Name of General Contractor b.Address
NORTH READING MA 01864 9784702860
C.City/Tom d.State e.Zip Cade f.Telephone
STATE NATIONAL
g.Contractor's Worker's Compensation Insurer
NFA0867332 12/28/2018
h.Policy# i.Expiration Date(MM/DD/YYYY)
6. What is the size of this facility? 255090 12
a.Square Feet b.#of Floors
C. Asbestos Transportation & Disposal
1.Transporter of asbestos-containing waste material from site of generation:
f a.Directly to Landfill or ry b.To Temporary Storage Location/Transfer Station
DEC-TAM CORPORATION 50 CONCORD STREET
c.Name of Transporter d.Address
Note:Temporary
storage of Asbestos NORTH READING MA 01864 9784702860
containing waste e.City7Town f.State g.Zip Code h.Telephone
material is only
allowed at the place
of business of a DLS 2.If a temporary storage location/transfer station is used,list name of transporter of asbestos containing
licensed Asbestos waste material from temporary storage location/transfer station to final disposal site:
contractor or a transferP rY g p
station that is
permitted by SERVICE TRANSPORTATION GROUP 58 PYLES LANE
MassDEP and a.Name of Transporter J.Address
operated in
compliance with Solid NEW CASTLE LE 19720 3027785930
Waste Regulations c.City/Town tl.State Z.Zip Code f.Telephone
310 CMR 19.000
Revised: 11/13/2013 Page 3 of 4
Massachusetts Department of Environmental Protection
s
Assbest
BWP AQ 04 (ANF-001) best Pr
os Project#
Asbestos Notification Form
(— Project Revision
)Project Cancellation
C.Asbestos Transportation& Disposal: (coat.)
3.Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
DEC-TAM CORPORATION 50 CONCORD STREET
a.Temporary Storage Location Name b.Address
NORTHRFADING MA 01864 9794702860
c.Cityrrown T Srate e.Zip Code f.Telephone
4.Name and location of final disposal site(asbestos landfill):
MIN H CfO RANDY BRIDGES
a.Final Disposal Site Name b.Final Disposal Site Owner Name
9000 MINERVA ROAD
c.Address
WAYNESBURG CH 44688 3308663435
d.City/Town e.State f.Zip Code g.Telephone
A Certification
SEAN CLEMENTS SEAN CLEMENTS
"1 certify that I have personally 1.Name 2.Authorized Signature
examined the foregoing and am SALES 3/28/2018
familiar with the information
contained in this document and 3.PositionrfNe 4.Date(MM/DD/YYYY)
sign this Note: or must 9784702860 DEC-TAM CORPORATION
s form
orm for DLS all attachments and that, based
notification purposes on my inquiry of those 5.Telephone 6.Representing
individuals immediately 50 CONCORD STREET NORTH READING
responsible for obtaining the 7.Address a.City/rown
information,I believe that the MA 01864
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
Massachusetts Department of Environmental Protection loozs357s
i BWP AQ 06 _
Notification Prior to Construction or Demolition Asbestos Project#
I-_ Project Revision
F Project Cancellation
A.Applicability
A Construction or Demolition operation of an industrial, commercial,or institutional building,or residential
building with 20 or more units is regulated by the Department of Environmental Protection(MassDEP),Bureau of
Waste Prevention,Air Quality Division,under Regulations 310 CMR 7.09.Notification of Construction or
Demolition operations is required under 310 CMR 7.09(2)ten(10)working days prior to any work being
performed.The following information is required pursuant to 310 CMR 7.09.
1.Is this a fee exempt notification(city,town,district,municipal housing authority,state facility,owner-occupied
residential property of four units or less)?
r a.Yes W b.No
2.Blanket Permit Project Approval,if applicable:
Approval to#
3.Non-Traditional Asbestos Abatement Work Practice Approval,if applicable:
Approval ID#
Instructions: B. Facility Description
1.All sections of this
form must be 1.Facility Information:
completed in order to PEOUOT HIGHLANDS 10-12 FIRST STREET
comply with the Department of a.Name of facility b.Street Address
Environmental SALEM MA 019700000 2077809800
Protection c.Cityfrown d.State e.Zip Code f.Telephone
notification
requirements of 310 CHNSTOPHERPODUN MANAGEMENT
CMR 7.09. g.Facility Contact Person h.Facility Contact Person Title
2.Submit Original 2077809800 CPOUUNQSILVERSTREETGROUP.COM
Form To: I.Facility Contact Person Telephone 1.Facility Contact Person Email
Commonwealth of
Massachusetts k.Facility Size:
P.O.Box 4062
Boston,MA 02211 255090 12
1.Square Feet 2.Number of Floors
MassDEP Use Only
1.Was the facility built prior to 1980? Fe I.Yes 1—2.No
m.Describe the current or prior use of the facility:
Date Received HOUSING
n.Is the facility a residential facility? f, 1.yes r 2.No o.If yes,how many units?250
2.Facility Owner: IW Same address as Facility
PEQUOT.SALEM LIMITED PARTNERSHIP CORP. 33 SILVER STREET SURE 200
a.Facility Owner Name b.Address
PORTLAND NE 041010000 2077809800
C.CityTown d.State e.Zip Code f.Telephone
3.Facility On-Site Manager/Owner Representative: r Same contact person as facility
W Same address as facility
F _ Same address as owner
CHRISTOPHER POULIN 10-12 FIRST STREET
a.On-Site Manager/Owner Representative b.Address
SALEM MA 01970 2077809800
c.Cityfrown d.State e.Zip Code f.Telephone
Revised:03/172014 Pagel of 3
l �j01olSa
Massachusetts Department of Environmental Protection 100283578
BWP AQ 06
Asbestos Project#
Notification Prior to Construction or Demolition
r Project Revision
(-- Project Cancellation
C. General Project Description
1. This project is: F New Construction F, Demolition F Renovation
2. Project Dates:
4/12/2018 4/12/2018
a.Project Start Date(MM/DD/YYYY) b.Project End Date(MM/DD/YYYY)
3. General Contractor:
DEC-TAM CORPORATION 50 CONCORD STREET
a.Name b.Address
NORTH READING MA 018640000 9784702860
c.City/Town d.State e.Zip Code I.Telephone
SEAN CLEMENTS 9784702860
g.General Contractor's On-site Manager/Foreman h.Telephone
4.Construction or demolition contractor: f� Same as General Contractor
DEC-TAM CORPORATION 50 CONCORD STREET
a.Contractor Name b.Address
NORTH READING MA 018640000 9784702860
c.City/Town d.State e.Zip Code L Telephone
SEAN CLEMENTS 9784702860
g.Construction and Demolition On-site Manager In.Telephone
5.Licensed Construction Supervisor:
SEAN CLEMENTS CS096523
a.Supervisor Name b.Construction Supervisor License(CSL)Number
6.is the entire facility to be demolished?
I a.Yes FV b.No
7.Describe the area(s)to be demolished:
FLOORING REPAIR
8.Describe the building(s)or addition(s)to be constructed:
9 a.Were the structure(s)surveyed for the presence of Asbestos-Containing V I.Yes f 2.No
Material(ACM)?
b. Who conducted the survey?
BRAIN PICCOLO A1061526
1.Name of Asbestos Inspector 2.DLS Certification#
Revised:03/17/2014 Page 2 of 3
Massachusetts Department of Environmental Protection -
BWP AQ 06 1100283578
- -- -
Asbestos Project#
Notification Prior to Construction or Demolition f- Project Revision
F- Project Cancellation
C. General Project Description (continued)
10 a. Was asbestos containing material(ACM)found? r 1.Yes r- 2.No
General b.if ACM was found during the survey,please provide the Asbestos 100283576
Statement:If Notification Form(ANY)Project Number.
asbestos is found
during a Construction 11.For demolition and construction projects,indicate dust suppression techniques to be used:
or Demolition I—
operation,all a.Seeding r b. Wetting F- c.Coverings d.Paving f- e.Shrouding
responsible parties
must comply with 310 l— f.Other-Specify:
CMR 7.00,7.09,7.15,
and Chapter 21 E of
the General Laws of 12.Is this an Emergency Demolition Operation? f-a.Yes r b.No
the Commonwealth.
This would include,
but would not be c.Name of MassDEP Official who evaluated the emergency
limited to,filing an
asbestos removal d.Title
with the
Department and/or a
notice of e.Date of Authorization(MM/DD/YYYY) f.MassDEP Waiver Number
releasefthreat of
release of a hazardous D. Certification
substance to the
Department,if "I certify that I have personally SEAN CLEMENTS
applicable. examined the foregoing and am 1.Print Name
familiar with the information SEAN CLEMENTS
contained in this document and 2.Authorized Signature
all attachments and that,based SALES
on my inquiry of those
individuals immediately 3.PositionRtle
responsible for obtaining the DECTAM CORPORATION
information,I believe that the 4.Representing
information is true,accurate,and 3/28/2018
complete. I am aware that there 5.Date(MWDD/YYYY)
are significant penalties for
submitting false information,
including possible fines and 6.P.E.#
imprisonment.The undersigned
hereby states,under the
penalties of perjury,that I am
aware that this permit
application or notification shall
not be deemed valid unless
payment of the applicable fee is
made."
Revised:03/17/2014 Page 3 of 3