1 FAIRFIELD STREET - ASBESTOSMassachusetts Department of Environmental Protection
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1117607
6/26/2019:12:53:40 PM
223.36K
DUDLEYSERVICES
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:100310522
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 2 of 2
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF001)
Project Revision Notification
100310522R1
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:
JOSH GILLIS 1 FAIRFIELD STREET
a. Name of Facility b. Street Address
SALEM MA 01970 0000000000
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. NonTraditional Asbestos Abatement Work Practice Approval,
if applicable:Approval ID #
7/16/2019 7/17/2019
a. Project Start Date (MM/DD/YYYY)b. End Date (MM/DD/YYYY)
8AM5PM 8AM5PM
c. Work Hours Monday Through Friday d. Work Hours Saturday & Sunday
Revised: 11/13/2013 Page 1 of 2
B. Other Project Revisions:
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 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."
SAMUEL NIGRO
1. Name
PRESIDENT
3. Position/Title
6179814280
5. Telephone
150L NEW BOSTON STREET
7. Address
MA
9. State
SAMUEL NIGRO
2. Authorized Signature
6/26/2019
4. Date (MM/DD/YYYY)
DUDLEY SERVICES
6. Representing
WOBURN
8. City/Town
01801
10. Zip Code
Revised: 11/13/2013 Page 2 of 2
Massachusetts Department of Environmental ProtectionBWP AQ 04 (ANF001)Project Revision Notification 100310522R1Asbestos 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:JOSH GILLIS 1 FAIRFIELD STREETa. Name of Facility b. Street AddressSALEMMA01970 0000000000c. City/Town d. State e. Zip Code f. TelephoneSAMUEL J. NIGRO III SUPERVISORg. Facility Contact Person Name h. Facility Contact Person TitleWorksite Location:BASEMENTi. Building Name, Wing, Floor, Room, etc.2. Blanket Permit Project Approval, if applicable:Approval ID #3. NonTraditional Asbestos Abatement Work Practice Approval,if applicable:Approval ID #7/16/2019 7/17/2019a. Project Start Date (MM/DD/YYYY)b. End Date (MM/DD/YYYY)8AM5PM 8AM5PMc. Work Hours Monday Through Friday d. Work Hours Saturday & Sunday
Revised: 11/13/2013 Page 1 of 2
B. Other Project Revisions:
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 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."
SAMUEL NIGRO
1. Name
PRESIDENT
3. Position/Title
6179814280
5. Telephone
150L NEW BOSTON STREET
7. Address
MA
9. State
SAMUEL NIGRO
2. Authorized Signature
6/26/2019
4. Date (MM/DD/YYYY)
DUDLEY SERVICES
6. Representing
WOBURN
8. City/Town
01801
10. Zip Code
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF001)
Project Revision Notification
100310522R1
Asbestos Project #
Project Revision
Project Cancellation