117 CONGRESS STREET - ASBESTOS RECEIVED 06/13/2017 04:11PM 9767450343 Salem Health Dept
jUNY13/2017/TUE 03: 22 PM FAX No, P, 002
i
Massachusetts Department Of Environmental Protection 100266374
BWP AQ 04 (ANF-001) Asbestos Project p
Asbestos Notification Form f Project Revision
f Project Cancellation
A.Asbestos Abatement Description
1.Feciliry Docarioo:
SALEM HOUSING AUn4ORfrY 177 CONGRESS Sm3EET
Instructions 1,All a.Name of Facllfy b,Street Addran
Sections ofthis form SALEM
must be computed in 214 01970 9764231300
order to comply with a.City/Town d.State e.Zip Code f,Telephone
MawDEP notification RANDY COMITO MAINTENANCE OPERATIONS MANAGER
requirements of 31 D
CMR 1.15 and 9.Faciliyr Contact Person Name It FaoTAy Contact Person Ti6a
Department of Labor Worksite LOcalmn: EXTERIOR WANDOW705-20
Standards ol-S)
notification i.Bulltling Name.W ng,Floor Roan eta
requirements of 453 2.Is the facility occupied? R a.Yes r-,b.No
CMR6A2
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 C b.No
M=DEP Use Only
4-Blanket Permit Project Approval,if applicable:
Date Received Approval ID#
5.Non-Traditional Asbestos Abatement Work Practice Approval,
2.Submit Original 11'appliQk1c: Approval lo#
Farm To
commonwaalth of
Massachusetts 6.Asbestos Contractor:
P.O.Box 4062
Boston,MA 02211 ENVIRONMENTAL RESTORATIONS OIC 25 SPALDING ROAD,STE17-2
a Name b.Address
FREEMONT Ni 03044 6038950400
C Ciry/rown d.State e.2ip Code f Telephone
ACOOD258 h.Contract Type:f7 1,Written. r'2.Verbal
g.DLS License#
? STUAT-GREGERMAN A8032545
a.Name of Contreoloes On-Site SupeMsorlFonsman In.DL$Certification
8 WA
a.Name of Project Monitor b.DLS Carefication#
9. N/A
a.Name of Asbestos Analytical Lab b.DLS Certification#
10.
6127/2017 6/2812017
a.Prof 2ct Stan Date(MMrDDNYYY) b,end Date(MM/DDA YYV)
7:30 AM-400 PM N/A
0.Wok Hours-Monday Through Friday d.Work Hours-Saturday&Sunday
11.What type of project is this?
F a Demolition Pr b.Reaovation C" c.Repair r7 d.Other-Please Specify:
Revised: 11/13/2013 Page I of 4
RECEIVED 06/13/2017 04:11PM 9787450343 Salem Health Dept
JUV13/2017/TUE 03:22 PM FAX No, P, 003
i
Massachusetts Department of Environmental Protection 100266374
PWP AQ 04 (ANF-001)
Asbestos Project#
Asbestos Notification Form r' ProjectRevision
r Project Cancellation
A.Asbestos Abatement Description:(cont.)
12.Abatement procedures(check all that apply):
F7 a Glove Bag r' b.Encapsulation r' c.Enclosure r it.Disposal Only r e.Cleanup
F' E Full Containment 17 g.Other-Please Specify: VEMNG AND REMOVAL NMOLE
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:
20
1,Linear Feet(Lin.F6) 2.Square Fact(Sq.Ft.)
b.Boiler,Breaching,Duct, a Transite Pipe
Tank Surfacc Coatings 1.Lin.Ft. 2.Sq,Ft 1.Lin.Ft 2,Sq.Ft
d.Pipe Insulation e.Transite Shingles
1.Lin.FL 2.Sq.Ft 1.Lin.FL Z Sq.Ft
f.Splay-On Fireproofing g.Transite Panels
I.Lin.Ft. 2.Sq.Ft 1.Lia Ft. 2.Sq.R,
b,Cloths,Woven Fabrics i.Other-Plcasc Specify:
1.Lin.Ft 2.Sq.Ft
j.Insulating Cement ACM GAULNNG 20
1.Lin.Ft —2:Sq Ft 1,Un.Ft 2,Sq.Ft.
15.Describe the decontamination sysretn(s)to be rased:
DOUBLED SUfrED HEFAYAC
16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g)
6 MIL POLY BAGS DOUBLED LABELED
17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency:
a.Name of MaasDEP Offd.1 b.Title of MassDEP Official
a Data of Authormton(MWDDNYYY) d.Waiver#
e.Name of DLS Of6dal f.TiUe of oLS MIM
g.Date orAUtnor=lon(MM/ODNYYY) n.Waver#
IS.Do prevailing wage rates as per M.G.L.c.149,§26,27 or 27A—F apply to this r a.Yes r b.No
project?
Revised:11/13/2013 Page 2 of 4
RECEIVED 06/13/2017 04:11PM 9787450343 Salem Health Dept
JUN/13/2017/TUE 03:22 PM FAX No, P, 004
i
Massachusetts Department of Environmental Protection 100266374
SWP AQ 04 (ANF-001) Asbestos Project s
Asbestos Notification Form r7 Project Revision
r' Project Cancellation
B.Facility Description
1.Current or prior use of facility. RESIDENTIAL
2.Is the facility owner-occupied residential with 4 units or less?r— a Yes 7 b.No
3 SALEM HOUSING AUTHORITY 27 CHARTER STREET
a.Facility Owner Name b.Address
SALEM MA 01970 9767469595
O Chy(fown d.State e.Zip Code f.Telephone
4.-
CCMITO 16A RAINBOWTERRACE
a.Name of Facility Owner's On-Site Manager b,Address
SALEM MA 01970 9784231300
C.Gityrr0.m1 d.Side 7 Zip Code t Telephone
5 EMARONMENTAL RESTORATIONS,INC. 25 SPAULDING ROAD SUITE 17-2
a.Name of General Contractor b.Address
FREMDNT N1 03044 0038950400
c.Cltyrrown d.state e.Zip Code f.Telephone
GRANITE STATE INSURANCE CO.
g.Contractors WolKefs Compensation Insurer
1A000360187 91772017
It.Policy# I,ExplrM on Date(MMIDONYY71
000 3
6.What is the size of ibis facility? d.Square Feet It.#of Floore
C.Asbestos Transportation&Disposal
1.Transporter of eslxstos-containing waste material from site of generation:
r.", a.Directly to Landfill or P b-To Temporary Storage Locarion/Craasfer Station
ENVIRONMENTAL RESTORATIONS,INC 25 SPA(JONG ROAOSurm I7-2
A,Name of Tmnsporter d.Address
Now;Temporary
storage of Asbestos ANT Ni 03044 6038950400
containing waste e.City?own f.Steffi g.Zip Code In.Taephone
mafWial i5 only
allowed at the place
arbusmdeaara ods 2.If a temporary storage location/transferstation is used,list Mane of transporter of asbestos containing
Pcenaed Asbestos waste material from temporary storage location/transfer station to final disposal site:
contractor orelrensfer P �' g p
station that is
Permitted by SERVICE TRAN,9POHr GROUP 58 PYLES LANE
MassDEPand a.Name ofTrandpoder b.Address
operated Ia
compliance with Solid NEWCASTLE CE 19720 8779999559
waste Regulations
310 CMR 19.000 G City7rown d.State e.Zip Cade f,Telephone
Revised:11/132013 page 3 of 4
RECEIVED 06/13/2017 04:11PM 9787450343 Salem Health Dept
JUN7/13/2017/TUE 03:23 PM FAX No, P. 005
( 1 .
Massachusetts Department of Environmental Protection f 100266374
L7JBWP AQ 04 (ANF-001) Asbestos Pro ect#
Asbestos Notification Form J
f Project Revision
l— Project Cancellation
C.Asbestos 7radsportatiod ar Disposal:(cont)
3.Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
ETMROWENTALRESTORATIONS,INC to HAZEL DRIVE
e.Temporary Storage Location Name b.Address
HAMPSTEAD N4 03941 6038950400
c.Cltyrrmn d.state e.Zip code f.Telephone
4,Name and location of final disposal site(asbestos landfill):
MINERVAENTERPRiSES MINEt4VAENTERMSES
a.Final Disposal Site Name b.Final Disposal Site Owner Nam
8955 MINERVA ROAD
c.Address
V AYNESBURG OH 44088 3308893435
d,city Tr e.State f Zip Code 9,Telephone
D. Certification
STUARTGREGER"N STUARTGREGERMAN
"I certify that I have personally 1.Name 2.Authorized signature
examined the foregoing and am PME etE12017
familiar with the information a.PoStOoMlie 4.Data(MM1DDlYYYY)
Now;Contractor must contained in this document and
sign this form for OLS all attachments and that,based 603BOBD400 ENVIRONMENTAL RESTORATIONS.94
noaacanon purpose. on my inquiry of those 5.Telephone B.Representing
individuals Immediately Z5 SPAULDING ROAD SURE 47.9 FREMONT
responsible fur obtaining the 7.Address B.GhyTowlt
infOnhOrOn,I believe that the Ni 03044
information is true,accurate,and Q.Sad 10.Zip Code
complete.I am aware that there
are signlfteerd penalties for
submitgng false information,
including possible Tinea and
imprisonment.The undersigned
hereby states that I have Rad the
Commonwealth of
M065a0hu50Ua regulations
governing asbestos abatement
(453 CMR 6.00 promulgated by
the Deparbnent of Labor
standards and 310 CMR 7.15
promulgated by the Department
of Environmental Protection),
and that 1 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
RECEIVED 06/13/2017 04:11PM 9787450343 Salem Health Dept
JUN/13/2017/TUE 03:22 PM FAX No. F. 001
Environmental Restorations, Inc.
A professioralapproach to quafity service
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