27 Grant Road DEP ANF 8-10-20 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction#1214705 Page 1 of 4
'10Massachusetts Department of Environ tl 100331980
L;'
BWP AQ 04 (ANF-001) Asbestos Project#
Asbestos Notification Form AUG 1 0 202G Project Revision
Project Cancellation
CITY OF SALEEBOARD OF HEALTH
A. Asbestos Abatement Description
1. Facility Location:
iDALY 127 GRANT ROAD
a.Name of Facility b.Street Address
1 SALEM A MA 01970 [aid-Jc0-0000
c.City/Town d.State e.Zip Code f.Telephone
FX___ 1 Ix �
g.Facility Contact Person Name h.Facility Contact Person Title
Instructions 1.All Workslte Location: ]BASEMENT
sections of this form must i.Building Name,Wing,Floor,Room,etc.
be completed in order to
comply with MassDEP 2. Is the facility occupied? Vi a.Yes 171 b.No
notification requirements
of 310 CMR 7.15 and 3. Is this a fee exempt notification(city, town, district, municipal housing authority, state facility, or owner-
Department of Labor occupied residential property of four units or less)?P�a.Yes b.No
Standards(DLS)
notification requirements 4 Blanket Permit Project Approval, if applicable:
of 453 CMR 6.12
Approval ID#
5. Non-Traditional Asbestos Abatement Work Practice Approval, if applicable:
MassDEP Use Only Approval ID#
6.Asbestos Contractor:
Date Received NEW ENGLA14D SURFACE MAINTENANCE LLP 1 1850 WASHINGTON ST J
a.Name b.Address
IWEYMOUTH MA 02189 781-337-2117 1
c.City/Town d.State e.Zip Code f.Telephone
AC000196 h.Contract Type: [/1.Written 2.Verbal
g.DLS License#
7. IJOSE VILL.ALTA 5061825
a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification#
8. RICHARD K.BOWEN M061044
a.Name of Project Monitor b.DLS Certification#
9. FLI ENVIRONMENTAL INC �A000144
a.Name of Asbestos Analytical Lab b.DLS Certification#
10.08/21/2020 08/21/2020
a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY)
7-4 NIA
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 L 1 b.Encapsulation �c.Enclosure d.Disposal Only e.Cleanup �j f.Full Containment
Cg.Other-Please Specify: — — —
https://edep.dep.mass.gov/eDEP/WebForms/Asbestos/BWPANF001.aspx 8/7/2020
AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction#1214705 Page 2 of 4
13.Job is being conducted: i a.Indoors - b.Outdoors
14 a. Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:
13I _I J
1.Linear Feet(Lin.Ft.) 2,Square Feet(Sq.Ft.)
b.Boiler,Breaching,Duct,Tank c.Transite Pipe
Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
d.Pipe Insulation 130 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 r_�F
1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
15. Describe the decontamination system(s):to be used:
AS REQUIRED
16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g):
AS REQUIRED
17. For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the
emergency:
a.Name of MassDEP Official b.Title of MassDEP Official
1 1
c.Date of Authorization(MM/DD/YYYY) d.Waiver#
e.Name of DLS Official f.Title of DLS Official
jI I
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 Tla.Yesi I, b.No
project?
B. Facility Description
1. Current or prior use of facility: i:ESIDENCE
2. Is the facility owner-occupied residential with 4 units or less? a.Yes b.No
3. [DALY 127 GRANT ROAD
a.Facility Owner Name b.Address
ISALEM MA 01970 000-000-0000
c.City/Town d.State e.Zip Code f.Telephone
4. ix
a.Name of Facility Owner's On-Site Manager b.Address
[MA-7 000-000-0000
c.City/Town d.State e.Zip Code f.Telephone
5. IX X
a.Name of General Contractor b.Address
https:Hedep.dep.mass.gov/eDEP/WebForms/Asbestos/BWPANFOOl.aspx 8/7/2020
AQ 04 -Asbestos Removal Notification Form ANF-001-Transaction#1214705 Page 3 of 4
x MA o0000 1000-000-0000
c.City/Town d.State e.Zip Code f.Telephone
x
g.Contractor's Worker's Compensation Insurer
01101/2021
h.Policy# i.Expiration Date(MM/DD/YYYY)
6.What is the size of this facility? 1400 F2
a.Square Feet b.#of Floors
Note:Temporary storage
of Asbestos containing C. Asbestos Transportation & Disposal
waste material is only
allowed at the place of 1. Transporter of asbestos-containing waste material from site of generation:
business of a DLS n a.Directly to Landfill or �/ b.To Temporary Storage Location/Transfer Station
licensed Asbestos "J
contractor or a transfer NEW ENGLAND SURFACE MAINTENANCE,LLP J 850 WASHINGTON STREET
station that is permitted
by MassDEP and c.Name of Transporter d.Address
operated in compliance
WEYMOUTH MA E1 99 I 781781-3
with Solid Waste e.City/Town f.State g.Zip Code h.Telephone
Regulations 310 CMR 2 If a temporary storage location/transfer station is used, list name of transporter of asbestos containing
19.000 waste material from temporary storage location/transfer station to final disposal site:
RED TECHNOLOGIES 110 NORTHWOOD DRIVE
a.Name of Transporter b.Address
BLOOMFIELD CT 06002 860-218-2428
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:
iRED TECHNOLOGIES 1203 PICKERING STREET
a.Temporary Storage Location Name b.Address
PORTLAND CT 06480 860-342-1022
c.City/Town d.State e.Zip Code f.Telephone
4. Name and location of final disposal site(asbestos landfill):
[MINERVA ENTERPRISES IMINERVA
a.Final Disposal Site Name b.Final Disposal Site Owner Name
9000 MINERVA ROAD
c.Address
Note:Contractor must WAYNESBURG I OH 44688 i330-866-3435
sign this form for DLS d.City/Town e.State f.Zip Code g.Telephone
notification purposes
D. Certification
"I certify that I have personally examined KEN FURTNEY 1 IKEN FURTNEY
the foregoing and am familiar with the 1.Name 2.Authorized Signature
information contained in this document PARTNER I 08/07/2020
and all attachments and that,based on — --
my inquiry of those individuals
3.Position/Title 4.Date(MM/DD/YYYY)
immediately responsible for obtaining 781-337-2117 NESM,LLP
the information,I believe that the 5.Telephone 6.Representing
information is true,accurate,and 850 WASHINGTON STREET WEYMOUTH
complete.I am aware that there are 7.Address 8.City/Town
significant penalties for submitting false
information,including possible fines and MA 102189
imprisonment.The undersigned hereby 9.State 10.Zip Code
states that I have read the
https:Hedep.dep.mass.gov/eDEP/WebForms/Asbestos/BWANFOOI.aspx 8/7/2020
AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction#1214705 Page 4 of 4
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."
https:Hedep.dep.mass.gov/eDEP/WebForms/AsbestosBWPANF001.aspx 8/7/2020