DEP Asbestos Removal Notification 7/16/20Massachusetts Department of Environmental Protection
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7/16/2020:4:26:57 PM
231.59K
RLAVALLEE
AQ 04 - Asbestos Removal Notification Form ANF-001
In Process
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF001) PreForm
Asbestos Notification Form
This is a revision to an existing form.
Project ID for existing form to be revised:
This job is being conducted under a Blanket Permit.
MassDEP assigned Blanket Authorization ID:
This job is being conducted under a Non Traditional Abatement Work Practice Permit.
MassDEP assigned Non Traditional Work Practice Authorization ID:
This job does not require the use of an asbestos contractor licensed by the MA Department of Labor Standards
because (please check one box below):
This job involves breaking, shearing or slicing of nonfriable asbestoscontaining material only (e.g. cement
shingles/panels, cement pipe, asphalt roofing or siding, vinyl floor tiles, etc.) in a manner that does not generate
asbestos dust or render the material friable, as allowed by the Department of Labor Standards (DLS) at 453 CMR
6.13(2)(a)5. All work must be done in compliance with the applicable regulations at 310 CMR 7.15; or
This job involves work on asbestos containing material that is classified by the Department of Labor Standards
(DLS) as a ‘SmallScale Asbestos Project,’ an ‘AsbestosAssociated Project’, or an ‘Asbestos Response Action’
by qualified ‘inhouse’ personnel as allowed by the Department of Labor Standards (DLS) at 453 CMR 6.00, and
will be performed in accordance with all the requirements of 453 CMR 6.13 (1)(a), 453 CMR 6.13 (2)(a)1. and 3.,
and 453 CMR 6.14 (1)(a), as applicable. All work must be done in compliance with the applicable regulations at
310 CMR 7.15.
None of the above conditions apply, generate a new form.
Revised: 11/13/2013 Page 1 of 1
Revised: 11/13/2013 Page 4 of 4
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF001)
Asbestos Notification Form
100330849
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
A. Asbestos Abatement Description
1. Facility Location:
25 COLONIAL ROAD 25 COLONIAL ROAD
a. Name of Facility b. Street Address
SALEM MA 01970 3392344036
c. City/Town d. State e. Zip Code f. Telephone
DOUG MALONE PROJECT MANAGER
g. Facility Contact Person Name h. Facility Contact Person Title
Worksite Location:ADMIN BUILDING
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
owneroccupied residential property of four units or less)?a. Yes b. No
4. Blanket Permit Project Approval, if applicable:
Approval ID #
5. NonTraditional Asbestos Abatement Work Practice Approval,
if applicable:Approval ID #
6. Asbestos Contractor:
ACM GROUP INC, DBA ACM ENVIRONMENTAL 7 LEWIS LN
a. Name b. Address
EAST HAMPSTEAD NH 03826 6033000537
c. City/Town d. State e. Zip Code f. Telephone
AC000964 h. Contract Type:1. Written 2. Verbal
g. DLS License #
7.FAUSTO D. SANTIAGO AS010394
a. Name of Contractor's OnSite Supervisor/Foreman b. DLS Certification #
8.N/A
a. Name of Project Monitor b. DLS Certification #
9.SAFETY ENVIRONMENTAL CONSULTANTS AA000233
a. Name of Asbestos Analytical Lab b. DLS Certification #
10.
7/29/2020 8/31/2020
a. Project Start Date (MM/DD/YYYY)b. End Date (MM/DD/YYYY)
MONDAYFRIDAY 7:303:30P
c. Work Hours Monday Through Friday d. Work Hours Saturday & Sunday
Revised: 11/13/2013 Page 1 of 4
A. Asbestos Abatement Description: (cont.)
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:
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:
90 11200
1. Linear Feet (Lin. Ft.)2. Square Feet (Sq. Ft.)
15. Describe the decontamination system(s) to be used:
3 CHAMBER DECON EQUIPPED WITH A 5 MICRON WATER FILTRATION SYSTEM FOR CLEAN WATER DISCHARGE
16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g):
ALL MATERIAL WILL BE THOROUGHLY WET AND PLACED IN 2 LAYERS OF SIX MIL POLY ASBESTOS LABELED BAGS
FOR PROPER HANDLING & TRANSPORT TO AN EPA APPROVED LANDFILL.
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
Revised: 11/13/2013 Page 2 of 4
11. What type of project is this?
a. Demolition b. Renovation c. Repair d. Other Please Specify:
B. Facility Description
1. Current or prior use of facility:COMMERCIAL
2. Is the facility owneroccupied residential with 4 units or less?a. Yes b. No
3.20 COLONIAL ROAD OWNWER LLC 55 CAMBRIDGE ST UNIT 300
a. Facility Owner Name b. Address
BURLINGTON MA 01803 7813652406
c. City/Town d. State e. Zip Code f. Telephone
4.DOUG MALONE 55 CAMBRIDGE ST
a. Name of Facility Owner's OnSite Manager b. Address
BURLINGTON MA 01803 7813652406
c. City/Town d. State e. Zip Code f. Telephone
5.R.J. KELLY CO., INC 55 CAMBRIDGE ST
a. Name of General Contractor b. Address
BURLINGTON MA 03466 7812722899
c. City/Town d. State e. Zip Code f. Telephone
STAR INSURANCE COMPANY
g. Contractor's Worker's Compensation Insurer
01F7WC0871071 11/30/2020
h. Policy #i. Expiration Date (MM/DD/YYYY)
6. What is the size of this facility?3500 1
a. Square Feet b. # of Floors
Revised: 11/13/2013 Page 3 of 4
C. Asbestos Transportation & Disposal
1. Transporter of asbestoscontaining waste material from site of generation:
a. Directly to Landfill or b. To Temporary Storage Location/Transfer Station
SERVICE TRANSPORT GROUP 301 OXFORD RD SUITE 803B
c. Name of Transporter d. Address
YARDLEY PA 19067 2673999411
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:
a. Name of Transporter b. Address
c. City/Town d. State e. Zip Code f. Telephone
C. Asbestos Transportation & Disposal: (cont.)
3. Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
a. Temporary Storage Location Name b. Address
c. City/Town d. State e. Zip Code f. Telephone
4. Name and location of final disposal site (asbestos landfill):
MINERVA LANDFILL MINERVA LANDFILL
a. Final Disposal Site Name b. Final Disposal Site Owner Name
8955 MINERVA RD
c. Address
WAYNESBURG OH 04468 3308663435
d. City/Town e. State f. Zip Code g. Telephone
b. Boiler, Breaching, Duct,
Tank Surface Coatings 1. Lin. Ft.2. Sq. Ft.
d. Pipe Insulation 50
1. Lin. Ft.2. Sq. Ft.
f. SprayOn 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:
JNTCMP TIL/MAS GROUT CAUL 40
1. Lin. Ft.
11200
2. Sq. Ft.
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
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."
ROBERT LAVALLEE
1. Name
PRESIDENT
3. Position/Title
6033191270
5. Telephone
50A NORTHWESTERN DR #10
7. Address
NH
9. State
ROBERT LAVALLEE
2. Authorized Signature
7/16/2020
4. Date (MM/DD/YYYY)
ACM GROUP INC
6. Representing
SALEM
8. City/Town
03079
10. Zip Code
Revised: 11/13/2013 Page 4 of 4
Massachusetts Department of Environmental ProtectionBWP AQ 04 (ANF001)Asbestos Notification Form 100330849Asbestos Project #Project RevisionProject CancellationInstructions 1. Allsections of this formmust be completed inorder to comply withMassDEP notificationrequirements of 310CMR 7.15 andDepartment of LaborStandards (DLS)notificationrequirements of 453CMR 6.12MassDEP Use OnlyDate 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
A. Asbestos Abatement Description1. Facility Location:25 COLONIAL ROAD 25 COLONIAL ROADa. Name of Facility b. Street AddressSALEMMA01970 3392344036c. City/Town d. State e. Zip Code f. TelephoneDOUG MALONE PROJECT MANAGERg. Facility Contact Person Name h. Facility Contact Person TitleWorksite Location:ADMIN BUILDINGi. Building Name, Wing, Floor, Room, etc.2. Is the facility occupied?a. Yes b. No3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, orowneroccupied residential property of four units or less)?a. Yes b. No4. Blanket Permit Project Approval, if applicable:Approval ID #5. NonTraditional Asbestos Abatement Work Practice Approval,if applicable:Approval ID #6. Asbestos Contractor:ACM GROUP INC, DBA ACM ENVIRONMENTAL 7 LEWIS LNa. Name b. AddressEAST HAMPSTEAD NH 03826 6033000537c. City/Town d. State e. Zip Code f. TelephoneAC000964h. Contract Type:1. Written 2. Verbalg. DLS License #7.FAUSTO D. SANTIAGO AS010394a. Name of Contractor's OnSite Supervisor/Foreman b. DLS Certification #8.N/Aa. Name of Project Monitor b. DLS Certification #9.SAFETY ENVIRONMENTAL CONSULTANTS AA000233a. Name of Asbestos Analytical Lab b. DLS Certification #10.7/29/2020 8/31/2020a. Project Start Date (MM/DD/YYYY)b. End Date (MM/DD/YYYY)MONDAYFRIDAY 7:303:30P
c. Work Hours Monday Through Friday d. Work Hours Saturday & Sunday
Revised: 11/13/2013 Page 1 of 4
A. Asbestos Abatement Description: (cont.)
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:
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:
90 11200
1. Linear Feet (Lin. Ft.)2. Square Feet (Sq. Ft.)
15. Describe the decontamination system(s) to be used:
3 CHAMBER DECON EQUIPPED WITH A 5 MICRON WATER FILTRATION SYSTEM FOR CLEAN WATER DISCHARGE
16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g):
ALL MATERIAL WILL BE THOROUGHLY WET AND PLACED IN 2 LAYERS OF SIX MIL POLY ASBESTOS LABELED BAGS
FOR PROPER HANDLING & TRANSPORT TO AN EPA APPROVED LANDFILL.
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
Revised: 11/13/2013 Page 2 of 4
11. What type of project is this?
a. Demolition b. Renovation c. Repair d. Other Please Specify:
B. Facility Description
1. Current or prior use of facility:COMMERCIAL
2. Is the facility owneroccupied residential with 4 units or less?a. Yes b. No
3.20 COLONIAL ROAD OWNWER LLC 55 CAMBRIDGE ST UNIT 300
a. Facility Owner Name b. Address
BURLINGTON MA 01803 7813652406
c. City/Town d. State e. Zip Code f. Telephone
4.DOUG MALONE 55 CAMBRIDGE ST
a. Name of Facility Owner's OnSite Manager b. Address
BURLINGTON MA 01803 7813652406
c. City/Town d. State e. Zip Code f. Telephone
5.R.J. KELLY CO., INC 55 CAMBRIDGE ST
a. Name of General Contractor b. Address
BURLINGTON MA 03466 7812722899
c. City/Town d. State e. Zip Code f. Telephone
STAR INSURANCE COMPANY
g. Contractor's Worker's Compensation Insurer
01F7WC0871071 11/30/2020
h. Policy #i. Expiration Date (MM/DD/YYYY)
6. What is the size of this facility?3500 1
a. Square Feet b. # of Floors
Revised: 11/13/2013 Page 3 of 4
C. Asbestos Transportation & Disposal
1. Transporter of asbestoscontaining waste material from site of generation:
a. Directly to Landfill or b. To Temporary Storage Location/Transfer Station
SERVICE TRANSPORT GROUP 301 OXFORD RD SUITE 803B
c. Name of Transporter d. Address
YARDLEY PA 19067 2673999411
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:
a. Name of Transporter b. Address
c. City/Town d. State e. Zip Code f. Telephone
C. Asbestos Transportation & Disposal: (cont.)
3. Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
a. Temporary Storage Location Name b. Address
c. City/Town d. State e. Zip Code f. Telephone
4. Name and location of final disposal site (asbestos landfill):
MINERVA LANDFILL MINERVA LANDFILL
a. Final Disposal Site Name b. Final Disposal Site Owner Name
8955 MINERVA RD
c. Address
WAYNESBURG OH 04468 3308663435
d. City/Town e. State f. Zip Code g. Telephone
b. Boiler, Breaching, Duct,
Tank Surface Coatings 1. Lin. Ft.2. Sq. Ft.
d. Pipe Insulation 50
1. Lin. Ft.2. Sq. Ft.
f. SprayOn 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:
JNTCMP TIL/MAS GROUT CAUL 40
1. Lin. Ft.
11200
2. Sq. Ft.
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
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."
ROBERT LAVALLEE
1. Name
PRESIDENT
3. Position/Title
6033191270
5. Telephone
50A NORTHWESTERN DR #10
7. Address
NH
9. State
ROBERT LAVALLEE
2. Authorized Signature
7/16/2020
4. Date (MM/DD/YYYY)
ACM GROUP INC
6. Representing
SALEM
8. City/Town
03079
10. Zip Code
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF001)
Asbestos Notification Form
100330849
Asbestos Project #
Project Revision
Project Cancellation
Revised: 11/13/2013 Page 4 of 4
Massachusetts Department of Environmental ProtectionBWP AQ 04 (ANF001)Asbestos Notification Form 100330849Asbestos Project #Project RevisionProject CancellationInstructions 1. Allsections of this formmust be completed inorder to comply withMassDEP notificationrequirements of 310CMR 7.15 andDepartment of LaborStandards (DLS)notificationrequirements of 453CMR 6.12MassDEP Use OnlyDate 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
A. Asbestos Abatement Description1. Facility Location:25 COLONIAL ROAD 25 COLONIAL ROADa. Name of Facility b. Street AddressSALEMMA01970 3392344036c. City/Town d. State e. Zip Code f. TelephoneDOUG MALONE PROJECT MANAGERg. Facility Contact Person Name h. Facility Contact Person TitleWorksite Location:ADMIN BUILDINGi. Building Name, Wing, Floor, Room, etc.2. Is the facility occupied?a. Yes b. No3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, orowneroccupied residential property of four units or less)?a. Yes b. No4. Blanket Permit Project Approval, if applicable:Approval ID #5. NonTraditional Asbestos Abatement Work Practice Approval,if applicable:Approval ID #6. Asbestos Contractor:ACM GROUP INC, DBA ACM ENVIRONMENTAL 7 LEWIS LNa. Name b. AddressEAST HAMPSTEAD NH 03826 6033000537c. City/Town d. State e. Zip Code f. TelephoneAC000964h. Contract Type:1. Written 2. Verbalg. DLS License #7.FAUSTO D. SANTIAGO AS010394a. Name of Contractor's OnSite Supervisor/Foreman b. DLS Certification #8.N/Aa. Name of Project Monitor b. DLS Certification #9.SAFETY ENVIRONMENTAL CONSULTANTS AA000233a. Name of Asbestos Analytical Lab b. DLS Certification #10.7/29/2020 8/31/2020a. Project Start Date (MM/DD/YYYY)b. End Date (MM/DD/YYYY)MONDAYFRIDAY 7:303:30Pc. Work Hours Monday Through Friday d. Work Hours Saturday & SundayRevised: 11/13/2013 Page 1 of 4A. Asbestos Abatement Description: (cont.)12. Abatement procedures (check all that apply):a. Glove Bag b. Encapsulation c. Enclosure d. Disposal Only e. Cleanupf. Full Containment g. Other Please Specify:13. Job is being conducted:a. Indoors b. Outdoors14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, orencapsulated:90 112001. Linear Feet (Lin. Ft.)2. Square Feet (Sq. Ft.)15. Describe the decontamination system(s) to be used:3 CHAMBER DECON EQUIPPED WITH A 5 MICRON WATER FILTRATION SYSTEM FOR CLEAN WATER DISCHARGE16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g):ALL MATERIAL WILL BE THOROUGHLY WET AND PLACED IN 2 LAYERS OF SIX MIL POLY ASBESTOS LABELED BAGSFOR PROPER HANDLING & TRANSPORT TO AN EPA APPROVED LANDFILL.17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency:a. Name of MassDEP Official b. Title of MassDEP Officialc. 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
Revised: 11/13/2013 Page 2 of 4
11. What type of project is this?a. Demolition b. Renovation c. Repair d. Other Please Specify:
B. Facility Description
1. Current or prior use of facility:COMMERCIAL
2. Is the facility owneroccupied residential with 4 units or less?a. Yes b. No
3.20 COLONIAL ROAD OWNWER LLC 55 CAMBRIDGE ST UNIT 300
a. Facility Owner Name b. Address
BURLINGTON MA 01803 7813652406
c. City/Town d. State e. Zip Code f. Telephone
4.DOUG MALONE 55 CAMBRIDGE ST
a. Name of Facility Owner's OnSite Manager b. Address
BURLINGTON MA 01803 7813652406
c. City/Town d. State e. Zip Code f. Telephone
5.R.J. KELLY CO., INC 55 CAMBRIDGE ST
a. Name of General Contractor b. Address
BURLINGTON MA 03466 7812722899
c. City/Town d. State e. Zip Code f. Telephone
STAR INSURANCE COMPANY
g. Contractor's Worker's Compensation Insurer
01F7WC0871071 11/30/2020
h. Policy #i. Expiration Date (MM/DD/YYYY)
6. What is the size of this facility?3500 1
a. Square Feet b. # of Floors
Revised: 11/13/2013 Page 3 of 4
C. Asbestos Transportation & Disposal
1. Transporter of asbestoscontaining waste material from site of generation:
a. Directly to Landfill or b. To Temporary Storage Location/Transfer Station
SERVICE TRANSPORT GROUP 301 OXFORD RD SUITE 803B
c. Name of Transporter d. Address
YARDLEY PA 19067 2673999411
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:
a. Name of Transporter b. Address
c. City/Town d. State e. Zip Code f. Telephone
C. Asbestos Transportation & Disposal: (cont.)
3. Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
a. Temporary Storage Location Name b. Address
c. City/Town d. State e. Zip Code f. Telephone
4. Name and location of final disposal site (asbestos landfill):
MINERVA LANDFILL MINERVA LANDFILL
a. Final Disposal Site Name b. Final Disposal Site Owner Name
8955 MINERVA RD
c. Address
WAYNESBURG OH 04468 3308663435
d. City/Town e. State f. Zip Code g. Telephone
b. Boiler, Breaching, Duct,Tank Surface Coatings 1. Lin. Ft.2. Sq. Ft.d. Pipe Insulation 501. Lin. Ft.2. Sq. Ft.f. SprayOn 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:JNTCMP TIL/MAS GROUT CAUL 401. Lin. Ft.112002. Sq. Ft.
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
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."
ROBERT LAVALLEE
1. Name
PRESIDENT
3. Position/Title
6033191270
5. Telephone
50A NORTHWESTERN DR #10
7. Address
NH
9. State
ROBERT LAVALLEE
2. Authorized Signature
7/16/2020
4. Date (MM/DD/YYYY)
ACM GROUP INC
6. Representing
SALEM
8. City/Town
03079
10. Zip Code
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF001)
Asbestos Notification Form
100330849
Asbestos Project #
Project Revision
Project Cancellation
Revised: 11/13/2013 Page 4 of 4
Massachusetts Department of Environmental ProtectionBWP AQ 04 (ANF001)Asbestos Notification Form 100330849Asbestos Project #Project RevisionProject CancellationInstructions 1. Allsections of this formmust be completed inorder to comply withMassDEP notificationrequirements of 310CMR 7.15 andDepartment of LaborStandards (DLS)notificationrequirements of 453CMR 6.12MassDEP Use OnlyDate ReceivedNote: Temporarystorage of Asbestoscontaining wastematerial is onlyallowed at the placeof business of a DLSlicensed Asbestoscontractor or a transferstation that ispermitted byMassDEP andoperated incompliance with SolidWaste Regulations310 CMR 19.000
Note: Contractor must
sign this form for DLS
notification purposes
A. Asbestos Abatement Description1. Facility Location:25 COLONIAL ROAD 25 COLONIAL ROADa. Name of Facility b. Street AddressSALEMMA01970 3392344036c. City/Town d. State e. Zip Code f. TelephoneDOUG MALONE PROJECT MANAGERg. Facility Contact Person Name h. Facility Contact Person TitleWorksite Location:ADMIN BUILDINGi. Building Name, Wing, Floor, Room, etc.2. Is the facility occupied?a. Yes b. No3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, orowneroccupied residential property of four units or less)?a. Yes b. No4. Blanket Permit Project Approval, if applicable:Approval ID #5. NonTraditional Asbestos Abatement Work Practice Approval,if applicable:Approval ID #6. Asbestos Contractor:ACM GROUP INC, DBA ACM ENVIRONMENTAL 7 LEWIS LNa. Name b. AddressEAST HAMPSTEAD NH 03826 6033000537c. City/Town d. State e. Zip Code f. TelephoneAC000964h. Contract Type:1. Written 2. Verbalg. DLS License #7.FAUSTO D. SANTIAGO AS010394a. Name of Contractor's OnSite Supervisor/Foreman b. DLS Certification #8.N/Aa. Name of Project Monitor b. DLS Certification #9.SAFETY ENVIRONMENTAL CONSULTANTS AA000233a. Name of Asbestos Analytical Lab b. DLS Certification #10.7/29/2020 8/31/2020a. Project Start Date (MM/DD/YYYY)b. End Date (MM/DD/YYYY)MONDAYFRIDAY 7:303:30Pc. Work Hours Monday Through Friday d. Work Hours Saturday & SundayRevised: 11/13/2013 Page 1 of 4A. Asbestos Abatement Description: (cont.)12. Abatement procedures (check all that apply):a. Glove Bag b. Encapsulation c. Enclosure d. Disposal Only e. Cleanupf. Full Containment g. Other Please Specify:13. Job is being conducted:a. Indoors b. Outdoors14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, orencapsulated:90 112001. Linear Feet (Lin. Ft.)2. Square Feet (Sq. Ft.)15. Describe the decontamination system(s) to be used:3 CHAMBER DECON EQUIPPED WITH A 5 MICRON WATER FILTRATION SYSTEM FOR CLEAN WATER DISCHARGE16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g):ALL MATERIAL WILL BE THOROUGHLY WET AND PLACED IN 2 LAYERS OF SIX MIL POLY ASBESTOS LABELED BAGSFOR PROPER HANDLING & TRANSPORT TO AN EPA APPROVED LANDFILL.17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency:a. Name of MassDEP Official b. Title of MassDEP Officialc. Date of Authorization (MM/DD/YYYY)d. Waiver #e. Name of DLS Official f. Title of DLS Officialg. 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 thisproject?a. Yes b. NoRevised: 11/13/2013 Page 2 of 411. What type of project is this?a. Demolition b. Renovation c. Repair d. Other Please Specify:B. Facility Description1. Current or prior use of facility:COMMERCIAL2. Is the facility owneroccupied residential with 4 units or less?a. Yes b. No3.20 COLONIAL ROAD OWNWER LLC 55 CAMBRIDGE ST UNIT 300a. Facility Owner Name b. AddressBURLINGTONMA01803 7813652406c. City/Town d. State e. Zip Code f. Telephone4.DOUG MALONE 55 CAMBRIDGE STa. Name of Facility Owner's OnSite Manager b. AddressBURLINGTONMA01803 7813652406c. City/Town d. State e. Zip Code f. Telephone5.R.J. KELLY CO., INC 55 CAMBRIDGE STa. Name of General Contractor b. AddressBURLINGTONMA03466 7812722899c. City/Town d. State e. Zip Code f. TelephoneSTAR INSURANCE COMPANYg. Contractor's Worker's Compensation Insurer01F7WC0871071 11/30/2020h. Policy #i. Expiration Date (MM/DD/YYYY)6. What is the size of this facility?3500 1a. Square Feet b. # of Floors
Revised: 11/13/2013 Page 3 of 4
C. Asbestos Transportation & Disposal1. Transporter of asbestoscontaining waste material from site of generation:a. Directly to Landfill or b. To Temporary Storage Location/Transfer StationSERVICE TRANSPORT GROUP 301 OXFORD RD SUITE 803Bc. Name of Transporter d. AddressYARDLEYPA19067 2673999411e. City/Town f. State g. Zip Code h. Telephone2. If a temporary storage location/transfer station is used, list name of transporter of asbestos containingwaste material from temporary storage location/transfer station to final disposal site:a. Name of Transporter b. Address
c. City/Town d. State e. Zip Code f. Telephone
C. Asbestos Transportation & Disposal: (cont.)
3. Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
a. Temporary Storage Location Name b. Address
c. City/Town d. State e. Zip Code f. Telephone
4. Name and location of final disposal site (asbestos landfill):
MINERVA LANDFILL MINERVA LANDFILL
a. Final Disposal Site Name b. Final Disposal Site Owner Name
8955 MINERVA RD
c. Address
WAYNESBURG OH 04468 3308663435
d. City/Town e. State f. Zip Code g. Telephone
b. Boiler, Breaching, Duct,Tank Surface Coatings 1. Lin. Ft.2. Sq. Ft.d. Pipe Insulation 501. Lin. Ft.2. Sq. Ft.f. SprayOn 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:JNTCMP TIL/MAS GROUT CAUL 401. Lin. Ft.112002. Sq. Ft.
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
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."
ROBERT LAVALLEE
1. Name
PRESIDENT
3. Position/Title
6033191270
5. Telephone
50A NORTHWESTERN DR #10
7. Address
NH
9. State
ROBERT LAVALLEE
2. Authorized Signature
7/16/2020
4. Date (MM/DD/YYYY)
ACM GROUP INC
6. Representing
SALEM
8. City/Town
03079
10. Zip Code
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF001)
Asbestos Notification Form
100330849
Asbestos Project #
Project Revision
Project Cancellation