11 CLEVELAND STREET-ASBESTOS NOTIFICATION FORM Massachusetts Department of Environmental Protection
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Username: HAZARDOUSPRO
Transaction ID: 1386312
Document: AQ 04-Asbestos Removal Notification Form ANF-001
Size of File: 231.26K
Status of Transaction: In Process
Date and Time Created: 7/512022:12:16:12 PM
Note: This file only includes forms that were part of your
transaction as of the date and time indicated above. If you need
a more current copy of your transaction, return to eDEP and
select to "Download a Copy" from the Current Submittals page.
LLi. Massachusetts Department of Environmental Protection
BWP AQ 04 (ANT-001)PreForm
Asbestos Notification Form
T_ This is a revision to an existing form.
Project ID for existing form to be revised:
r- This job is being conducted under a Blanket Permit.
MassDEP assigned Blanket Authorization ID:
1— This job is being conducted under a Non Traditional Abatement Work Practice Permit.
MassDEP assigned Non Traditional Work Practice Authorization ID:
T_ 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 non-friable asbestos-containing 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
r This job involves work on asbestos containing material that is classified by the Department of Labor Standards
(DLS)as a`Small-Scale Asbestos Project,'an`Asbestos-Associated Project',or an`Asbestos Response Action'
by qualified`in-house'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.
W None of the above conditions apply,generate a new form.
Revised: 11/13/2013 Page 1 of 1
' Massachusetts Department of Environmental Protection 100368638
BWP AQ 04 (ANF-001) Asbestos Project#
Asbestos Notification Form
� r' Project Revision
r' Project Cancellation
A. Asbestos Abatement Description
1.Facility Location:
COMMERCIAL 11 CLEVELAND ST
Instructions 1.All a.Name of Facility b.Street Address
sections of this form SALEM MA 01970 6179666781
must be completed in
order to comply with c.City/Town d.State e.Zip Code f.Telephone
MassDEP notification BRIDGETAROIE REPRESENTATIVE
requirements of 310
CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title
Department of Labor Worksite Location: BASEMENT
Standards(DLS) ,
notification i.BuildingName Win Floor,Room,etc.
9,
requirements of 453 2. Is the facility occupied? F a.Yes T b.No
CMR 6.12
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)? 1— a.Yes ry-1 b.No
MassDEP Use Only
4.Blanket Permit Project Approval,if applicable:
Date Received Approval ID#
5.Non-Traditional Asbestos Abatement Work Practice Approval,
if applicable: Approval ID#
6.Asbestos Contractor:
HAZARDOUS PRO LLC 10 BERRY ST
a.Name b.Address
NORTH ANDOVER MA 01845 9783978867
c.City/Town d.State e.Zip Code f.Telephone
AC001072 h.Contract Type:W 1.Written r-2.Verbal
g.DLS License#
7. JOSE W VAZQUEZ AS903804
a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification#
8 LUIGI MARANGIELLO AM900461
a.Name of Project Monitor b.DLS Certification#
9 ASBESTOS IDENTIFICATION LAB AA000208
a.Name of Asbestos Analytical Lab b.DLS Certification#
10.
7/21/2022 7/22/2022
a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY)
7-7 7-7
c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday
11.What type of project is this?
r a.Demolition W b.Renovation J- c.Repair I- d.Other-Please Specify:
Revised: 11/13/2013 Page 1 of 4
Massachusetts Department of Environmental Protection B 100368638
WP AQ 04 (ANF-001)
Asbestos Project#
Asbestos Notification Form
r � Project Revision
Project Cancellation
A.Asbestos Abatement Description:(cont.)
12.Abatement procedures(check all that apply):
W a.Glove Bag r b.Encapsulation r- c.Enclosure T_ d.Disposal Only r e.Cleanup
r f Full Containment r g. Other-Please Specify:
13.Job is being conducted: W a.Indoors r- b.Outdoors
14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:
538
1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.)
b.Boiler,Breaching,Duct, c.Transite Pipe
Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
d.Pipe Insulation 538 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
1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
15.Describe the decontamination system(s)to be used:
GLOVE BAG,3 CHAMBER DECON
16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g):
WET METHOD,DOUBLE BAGGED,LABELED
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 r- a.Yes r b.No
proj ect?
Revised: 11/13/2013 Page 2 of 4
Massachusetts Department of Environmental Protection 100368638
-� BWP AQ 04 (ANF-001)
Asbestos Project#
Asbestos Notification Form
� Project Revision
` r Project Cancellation
B. Facility Description
1.Current or prior use of facility: COMMERCIAL
2.Is the facility owner-occupied residential with 4 units or less? r— a.Yes W b.No
3 SAINTEANNE PARISH 11 CLEVELAND ST
a.Facility Owner Name b.Address
SALEM MA 01970 6179666781
c.City/Town d.State e.Zip Code f.Telephone
4 HAZARDOUS PRO 3 DUNDEE PARK
a.Name of Facility Owner's On-Site Manager b.Address
ANDOVER MA 01810 9783978867
c.City/Town d.State e.Zip Code f.Telephone
5 HAZARDOUS PRO 3 DUNDEE PARK
a.Name of General Contractor b.Address
ANDOVER MA 01810 9783978867
c.City/Town d.State e.Zip Code f.Telephone
PAM INSURANCE COMPANY
g.Contractor's Worker's Compensation Insurer
WCMA000259200 11/5/2022
h.Policy# i.Expiration Date(MM/DD/YYYY)
6.What is the size of this facility? 43560 2
a.Square Feet b.#of Floors
Note:Temporary storage of Asbestos C.Asbestos Transportation& Disposal
containing waste 1.Transporter of asbestos-containing waste material from site of generation:
material is only
allowed at the place r— a.Directly to Landfill or rV b_To Temporary Storage Location/Transfer Station
of business of a DLS
licensed Asbestos
contractor or a transfer HAZARDOUS PRO 3 DUNDEE PARK
station that is c.Name of Transporter d.Address
permitted by
MassDEP and ANDOVER MA 01810 9783978867
operated in e.City/Town f.State g.Zip Code h.Telephone
compliance with Solid
Waste Regulations
310 CMR 19.000 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:
JOB ROLL OFF INC PO BOX 609
a.Name of Transporter b.Address
HAMPSTEAD MA 03841 4135389200
c.City/Town d.State e.Zip Code f.Telephone
Revised: 11/13/2013 Page 3 of 4
Massachusetts Department of Environmental Protection 100368638
BWP AQ 04 (ANF-001)
Asbestos Project#
Asbestos Notification Form
Project Revision
f— Project Cancellation
C.Asbestos Transportation&Disposal: (cont.)
3.Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
HAZARDOUS PRO 3 DUNDEE PARK
a.Temporary Storage Location Name b.Address
ANDOVER MA 01810 9783978867
c.City/Town d.State e.Zip Code f.Telephone
4.Name and location of final disposal site(asbestos landfill):
TURNKEY LANDFILL WASTE MANAGEMENT OF NH
a.Final Disposal Site Name b.Final Disposal Site Owner Name
200 ROCHESTER NECK RD
c.Address
ANDOVER MA 01810 9783978867
d.City/Town e.State f.Zip Code g.Telephone
Note:Contractor must
sign this form for DLS
notification purposes A Certification
AMADYSON RAFAEL AMADYSON RAFAEL
"I certify that I have personally 1.Name 2.Authorized Signature
examined the foregoing and am CONTRACTOR 7/5/2022
familiar with the information
3.PositionlTitle 4.Date(MM/DD/YYYY)
contained in this document and
all attachments and that,based 9783978867 HAZARDOUS PRO
on my inquiry of those 5.Telephone 6.Representing
individuals immediately 3DUNDEEPARK ANDOVER
responsible for obtaining the 7.Address 8.City/Town
information,I believe that the MA 01810
information is true,accurate,and
complete. I am aware that there 9•State 10.Zip Code
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."
Revised: 11/13/2013 Page 4 of 4