30 Shore Ave, Salem, MA - ANF-REVISED4/7/2020 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction #1188639
https://edep.dep.mass.gov/eDEP/WebForms/Asbestos/BWPANF001.aspx 1/2
B. Other Project Revisions:
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)
Project Revision Notification
100326540R1
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
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
Project History
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. Blanket Permit Project Approval, if applicable:
Approval ID #
3. Non-Traditional Asbestos Abatement Work Practice Approval, if applicable:
Approval ID #
04/15/2020 04/15/2020
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
C. 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
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
SAMUEL NIGRO
1. Name
PRESIDENT
3. Position/Title
617-981-4280
5. Telephone
150-L NEW BOSTON STREET
7. Address
MA
9. State
SAMUEL NIGRO
2. Authorized Signature
04/07/2020
4. Date (MM/DD/YYYY)
DUDLEY SERVICES
6. Representing
WOBURN
8. City/Town
01801
10. Zip Code
4/7/2020 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction #1188639
https://edep.dep.mass.gov/eDEP/WebForms/Asbestos/BWPANF001.aspx 2/2
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."