30 Shore Ave, Salem, MA - ANF4/7/2020 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction #1188428
https://edep.dep.mass.gov/eDEP/WebForms/Asbestos/BWPANF001.aspx 1/4
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
100326540
Asbestos Project #
Project Revision
Project Cancellation
Instructions 1. All
sections of this form must
be completed in order to
comply with MassDEP
notification requirements
of 310 CMR 7.15 and
Department of Labor
Standards (DLS)
notification requirements
of 453 CMR 6.12
MassDEP Use Only
Date Received
A. Asbestos Abatement Description
1. Facility Location:
MARGARET JALBERT 30 SHORE AVE.
a. Name of Facility b. Street Address
SALEM MA 01970 000-000-0000
c. City/Town d. State e. Zip Code f. Telephone
SAMUEL J. NIGRO III SUPERVISOR
g. Facility Contact Person Name h. Facility Contact Person Title
Worksite Location:BASEMENT
i. Building Name, Wing, Floor, Room, etc.
2. Is the facility occupied?a. Yes b. No
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 b. No
4. Blanket Permit Project Approval, if applicable:
Approval ID #
5. Non-Traditional Asbestos Abatement Work Practice Approval, if applicable:
Approval ID #
6. Asbestos Contractor:
DUDLEY SERVICES INC 150-L NEW BOSTON STREET
a. Name b. Address
WOBURN MA 01801 781-270-2650
c. City/Town d. State e. Zip Code f. Telephone
AC000112 h. Contract Type: 1. Written 2. Verbal
g. DLS License #
7.SAMUEL J NIGRO III AS032802
a. Name of Contractor's On-Site Supervisor/Foreman b. DLS Certification #
8.PATRICIA EILEEN RILEY AM060297
a. Name of Project Monitor b. DLS Certification #
9.ENVIRO-SAFE ENGINEERING AA000131
a. Name of Asbestos Analytical Lab b. DLS Certification #
10.04/16/2020 04/16/2020
a. Project Start Date (MM/DD/YYYY)b. End Date (MM/DD/YYYY)
8AM-5PM 8AM-5PM
c. Work Hours - Monday Through Friday d. Work Hours - Saturday & Sunday
11. What type of project is this?
a. Demolition b. Renovation c. Repair d. Other - Please Specify:
12. Abatement procedures (check all that apply):
a. Glove Bag b. Encapsulation c. Enclosure d. Disposal Only e. Cleanup f. Full Containment
g. Other - Please Specify:
4/7/2020 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction #1188428
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13. Job is being conducted:a. Indoors b. Outdoors
14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or
encapsulated:
100
1. Linear Feet (Lin. Ft.)2. Square Feet (Sq. Ft.)
15. Describe the decontamination system(s) to be used:
16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g):
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
project?
a. Yes b. No
B. Facility Description
1. Current or prior use of facility:RESIDENTIAL DWELLING
2. Is the facility owner-occupied residential with 4 units or less?a. Yes b. No
3.MARGARET JALBERT 30 SHORE AVE.
a. Facility Owner Name b. Address
SALEM MA 02301 000-000-0000
c. City/Town d. State e. Zip Code f. Telephone
4.N/A N/A
a. Name of Facility Owner's On-Site Manager b. Address
POLY CONTAINMENT BARRIER WITH CLEAN ROOM USING NEGATIVE AIR SYSTEM AND HEPA VACUUM
ADEQUATELY WET ASBESTOS PROPERLY SEALED IN DOUBLE SIX MIL POLY BAGS PLACARDED FOR
ASBESTOS IDENTIFICATION
b. Boiler, Breaching, Duct, Tank
Surface Coatings 1. Lin. Ft. 2. Sq. Ft.
d. Pipe Insulation 100
1. Lin. Ft. 2. Sq. Ft.
f. Spray-On Fireproofing
1. Lin. Ft. 2. Sq. Ft.
h. Cloths, Woven Fabrics
1. Lin. Ft. 2. Sq. Ft.
j. Insulating Cement
1. Lin. Ft. 2. Sq. Ft.
c. Transite Pipe
1. Lin. Ft. 2. Sq. Ft.
e. Transite Shingles
1. Lin. Ft. 2. Sq. Ft.
g. Transite Panels
1. Lin. Ft. 2. Sq. Ft.
i. Other - Please Specify:
1. Lin. Ft. 2. Sq. Ft.
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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
notification purposes
N/A MA 00000 000-000-0000
c. City/Town d. State e. Zip Code f. Telephone5.N/A N/A
a. Name of General Contractor b. Address
N/A MA 00000 000-000-0000
c. City/Town d. State e. Zip Code f. Telephone
AIM MUTUAL
g. Contractor's Worker's Compensation Insurer
7026686 07/09/2020
h. Policy #i. Expiration Date (MM/DD/YYYY)
6. What is the size of this facility?2000 2
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 b. To Temporary Storage Location/Transfer Station
DUDLEY SERVICES 150-L NEW BOSTON STREET
c. Name of Transporter d. Address
WOBURN MA 01801 617-981-4280
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:
J.O.B. ROLLOFF PO BOX 6037
a. Name of Transporter b. Address
CHELSEA MA 02150 617-981-4280
c. City/Town d. State e. Zip Code f. Telephone
3. Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
N/A N/A
a. Temporary Storage Location Name b. Address
N/A MA 00000 000-000-0000
c. City/Town d. State e. Zip Code f. Telephone
4. Name and location of final disposal site (asbestos landfill):
TURNKEY LANDFILL WASTE MANAGEMENT
a. Final Disposal Site Name b. Final Disposal Site Owner Name
97 ROCHESTER NECK ROAD
c. Address
ROCHESTER NH 03869 800-847-5303
d. City/Town e. State f. Zip Code g. Telephone
D. Certification
"I certify that I have personally examined
the foregoing and am familiar with the
information contained in this document
and all attachments and that, based on
my inquiry of those individuals
immediately responsible for obtaining
the information, I believe that the
information is true, accurate, and
SAMUEL NIGRO
1. Name
PRESIDENT
3. Position/Title
617-981-4280
5. Telephone
150-L NEW BOSTON STREET
SAMUEL NIGRO
2. Authorized Signature
04/06/2020
4. Date (MM/DD/YYYY)
DUDLEY SERVICES
6. Representing
WOBURN
4/7/2020 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction #1188428
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complete. I am aware that there 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."
7. Address
MA
9. State
8. City/Town
01801
10. Zip Code