13 GALLOWS HILL ROAD - ASBESTOS Massachusetts Department of Environmental Protectio 100374963
BWP AQ 04 rANF-001 RECEIVE� Asbestos Project#
' Asbestos Notification Form
Project Revision
OCT 2 4 2022 d Project Cancellation
BOARD OF HEALTH
A. Asbestos Abatement Description
1. Facility Location:
ISHERIDAN i13 GALLOW HILLS ROAD
a.Name of Facility b.Street Address
SALEM v MA 01970 000- 000-6000
c.City/Town d.State e.Zip Code f.Telephone
X Ix
g.Facility Contact Person Name h.Facility Contact Person Title
Instructions 1.All WorkSite Location: ATTIC
sections of this form must i.Building Name,Wing,Floor,Room,etc.
be completed in order to -1
comply with MassDEP 2. Is the facility occupied? I a.Yes �1 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)? a.Yes d 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: 1
MassDEP Use Only Approval ID#
6.Asbestos Contractor:
Date Received NEW ENGLAND SURFACE MAINTENANCE LLP 850 WASHINGTON ST
a.Name b.Address
WEYMOUTH 102189 i781-337-2117
c.City/Town d.State e.Zip Code f.Telephone
AC000196 h.Contract Type: 1.Written 2.Verba
g.DLS License#
7. 1 ELMER E,PINEDA AS001291
a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification#
8. 1 N/A
a.Name of Project Monitor b.DLS Certification#
9. _ _ J I N/A
a.Name of Asbestos Analytical Lab b.DLS Certification#
10. 11/04/2022 1 11/04/2022
a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY)
17AM-4 N/A
c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday
11.What type of project is this?
a.Demolition f�b.Renovation E 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
nu 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:
200
1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.)
b.Boiler,Breaching,Duct,Tank � c.Transite Pipe
I
Surface Coatinqs F+ 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
d.Pipe Insulation e.Transite Shingles
1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
f.Spray-On Fireproofing g.Transite Panels �I
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 VERMICULITE
[200
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:
J
a.Name of MassDEP Official b.Title of MassDEP Official
c.Date of Authorization(MM/DD/YYYY) d.Waiver#
{ 1
e.Name of DLS Official f.Title of DLS Official
� L
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 ❑a.Yes❑b.No
project?
B. Facility Description
1. Current or prior use of facility: RESIDENCE
2. Is the facility owner-occupied residential with 4 units or less? a.Yes i b.No
L
3. ISHERIDAN 13 GAL-LOW HILLS ROAD
a.Facility Owner Name b.Address
I SALEM MA 01970 000-000-0000
c.City/Town d.State e.Zip Code f.Telephone
4. X � x
a.Name of Facility Owner's On-Site Manager b.Address
x MA 100000 000-000-0200
0'.C_x zilx
a.Name of General Contractor b.Address
F 1 MA 100000 11000-000-0000
c.City/Town d.State e.Zip Code f.Telephone
X
g.Contractor's Worker's Compensation Insurer
X 01/01/2023
h.Policy# i.Expiration Date(MM/DD/YYYY)
6. What is the size of this facility? 11400 .2
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
a.Directly to Landfill or b.To Temporary Storage Location/Transfer Station
licensed Asbestos
contractor or a transfer
station that is permitted NEW ENGLAND SURFACE MAINTENANCE,LLP 850 WASHINGTON STREET
by MassDEP and c.Name of Transporter d.Address
operated in compliance 1WEYMOUTH f MA 02189 F781-337-2117
with Solid Waste e.City/Town f.State g.Zip Code h.Telephone
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:
RED TECHNOLOGIES �, 173 PICKERING STREET
a.Name of Transporter b.Address
IFORTLAND CT 06480 860-342-1022
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:
RED TECHNOLOGIES 173 PICKERING STREET
a.Temporary Storage Location Name b.Address
0RRTLANO CT 06480 860-342-1022
c.CityfTown d.State e.Zip Code f.Telephone
4. Name and location of final disposal site (asbestos landfill):
MINERVA ENTERPRISES MINERVA
a.Final Disposal Site Name b.Final Disposal Site Owner Name
9000 MINERVA ROAD I
c.Address
Note:Contractor must WAYNESBURG _ OH 44688 330-866-3435
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 IJIM DOYLE J JIM DOYLE
the foregoing and am familiar with the 1.Name 2.Authorized Signature
information contained in this document �pARTNER �� 10/1L_9/2022
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,L L P
the information,I believe that the 5.Telephone 6.Representing
information is true,accurate,and [17813372117 IWEYMOUTH }
complete.I am aware that there are 7.Address 8.City/Town
significant penalties for submitting false MA 02189
information,including possible fines and 9.State 10.Zip Code
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."