11 GOODHUE STREET - ASBESTOS Massachusetts Department of Environmental Protection 1002.1 3 - 9 -`--
B" AQ 04 (ANF-001)
LL7i, -
Assbestosbestos Project#
Asbestos Notification Form - Project Revision
Project Cancellation
A. Asbestos Abatement Description
1.Facility Location:
VACANT BUILDING 11 GOODHUE STREET
Instructions 1.All a.Name of Facility b.Street Address
sections of this forth SALEM MA 01970 00000000W
most be completed M
order to comply with o.Cityrrown d.State e.Zip Code f.Telephoner
MmDEP noOficadon ANTHONYROBERTO oyyl Bm
requirements of 310
CMR 7.15 and g.Facility Contact Person Name h.Facky Contact Person Tim
Department of Labor Worksite Location: ROOF
Standards(DLS) i.Buftng Name,Wing,Floor,Room,etc
notification
requirements of453 2. Is the facility occupied? r-a.Yes W b.No
CMR&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)? I- a Yes W b.No
MasaDEP Use Only
4.Blanket Permit Project Approval,if applicable:
Date Received Approval to#
5.Non-Traditional Asbestos Abatement Work Practice Approval,
2 Submit Onginal if applicable: Appmval to#
Farm To.
Commonwealth of
Massachusetts 6.Asbestos Contractor:
P.O.Box 4062
Boston,MA 02211 SB4CAM INC 741 SOUTH MAW ST
a.Name b.Address
HAVERHILL MA 01835 9786837767
c.CityRovn d.State e.Zip Code I.Telephone
AC000129 h.Contract Typc: ,.t'• 1.Written r 2.Verbal
9.DLS License#
7 PABLO A.NUNEZ ASOM514
a.Name of Contractors Op.Site SuperoisodPoreman b.DLS Certification If
8. ENVIRO-SAFE ENGINEERING DBA AA000131
a.Name of Pr<yect Mon b.DLS Certification#
9. ENAROWE ENGINEERING AA000131
a.Name of Asbestos Analytical tab In.DLS C: dfica0on#
10.
10/1112017 1020/2017
a.Project Start Date(MMIDDtMY) b.End Date(MWDDIYYYY)
7AW12PM NOTAPPI IC
c.Work Hours-Monday Through Friday d.Wok Hours-Saturday&Sunday
I I_What type of project is this?
f—V a Demolition r- b.Renovation f- c.Repair r- d.Other-Please Specify:
k
Revised: 11l13/2013 Page I of 4
Massachusetts Department of Environmental Protection �002---
----^
3659
BWP AQ 04 (ANF-001) -- —
Asbestos Project ect#
Asbestos Notification Form F- Project Revision
f Project Cancellation
A.Asbestos Abatement Description:(cons.)
12,Abatement procedures(check all that apply):
f" a.Glove Bag r— b.Encapsulation r- c.Enclosure r d.Disposal Only r- e.Cleanup
r- 1.Full Containment W g Other-Please Specify: NON FRIABLE RE OVAL METHODS
13.Job is being conducted: f a.Indoors Wo b.Outdoors
14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:
2000
1.Un iar Feet(Lin.Ft) 2.Square Feet fan.Ft)
b.Boner,Breaching,Duct, a Transite Pipe
Tank Surface Coatings i.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft 2.Sq.Ft.
it,Pipe Insulation e.Transite Shingles
1.Lin.Ft 2.Sq.Ft. 1.Lin.Ft 2.Sq.Ft
C 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.FL
j. Insulating Cement ROOF FELTS ANDRASNING4 2000
1.Lin.Ft 2.Sq.Ft 1.Lin.Ft 2.Sq.Ft.
15. Describe the decontamination system(s)to be used:
REWTEDECON UNIT
16.Describe the containerization/disposal methods to comply with 310 CMR T 15 and 453 CMR 6.14(2)
(g):
WASTE WETTEDAXXJBLE BAGGED IN 6 MIL LANDFILL
17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency:
I
a.Name of MassDEP Official b.Tafe of MassDEP Official
c.Date of Autnodutien(MMrDDIYYYY) d.waiver n
a.Narne of OILS Official I.Title of DLS Official
g.Date of Authorization(MM()D(YYYY) In.Waiver 9
18. Do prevailing wage rates as per M.G.L.c. 149,y 26,27 or 27A-F apply to this f- a Yes ry b.No
Project?
Revised: 111132013 Page 2 of 4
Massachusetts Department of Environmental Protection 100273659
BWP AQ 04 (ANF-001)
Asbestos Project#f
Asbestos Notification Form
r Project Revision
{ t� Project Cancellation
B.Facility Description
1.Current or prior rise of facility: VACANT BOLDING
2.is the facility owner-occupied residential with 4 units or leso fi a.Yes W, b.No
3.IARPROPERITES 282BENNINGT(NIS'TREEF
a.Facility Owner Name b.Address
BOSTON MA 02128 6175671992
C.Cityfrown cF State e.Zip Code I.Telephone
4 ANTHONY ROBERTO SAME
a.Name of FacA ty Owner's On-Site Manager b.Address
SAME MA 02128 6175671992
c.Cityrrown d.State e.ZIP,Code L Telephone
S NOT APPLICABLE SAME
a.Name of General Contractor In.Address
SAME MA D2128 0000000006
a Cilyfrown d.State e.Zip Code f Telephone
UBERTY MUTUAL INSURANCE COMPANY
g.Contractor's Worked's Compensation Insurer
WCS-319481104-046 12)2012017
h.Policy# I.Expiration Date(MWDD/YYYY)
6.What is the sizeof this facility. 2000 1
a.Square Feet b.#of Floors
C.Asbestos Transportation & Disposal
1.Transporter of asbestos-containing waste material from site of generation:
r a.Directly to landfill or Fw b.To Temporary Storage Location/Transfer Station
SENCAM,INC. 741 SOUTH MAIN STREET
c.Name of Transporter d.Address
Note:Temporary HAVERHILL MA 01835 9786837767
storage of Asbestos _
containing waste e.City/Town 1.State 9.Zip Code h.Telephone
material is only
allowed at the prow
of business of a DLS 2.if a temporary storage location/transfer station is used.I ist name of transporter of asbestos containing
licensed Asbestos
cwttracoro or a tnios r a waste material from temporary storage locationftr'ansfer station to final disposal site:
bote
station that is
permitted by SERVICETRANSPORTGROUP 58 PYLES LANE
MassDEP and a.Name of Trenspoder b.Address
operatod in
compliance with Solid NEW GASFLE tE 19720 8779999559
Waste Regulations c_CitylTown d.State e.Zip Code f.Telephone
310 CMR 19.000
Revised: 11/13/2013 Page 3 of 4
R
Massachusetts Department of Environmental ProtectionL-
- ---
BWP AQ 04 (ANF-001) 100273e59
Asbestos Notification Form Asbestos Project#
i Project Revision
i" Project Cancellation
C.Asbestos Transportation&Disposal:(cont.)
3.Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
SEi,iew INC. 741 SOUTH MAIN STREET
a.Temporary Storage Location Name b.Address
HAVERHILL MA 01835 9786837767
c.City/Town d.State e.Zip Code f.Talephone
4.Name and location of final disposal site(asbestos landfill):
MINERVA1ANDFU t1WNUMJ
a.Final Disposal Site Name b.-Final Disposal Sue Owner Name
9000 MINERVA ROAD
c Address
WAYNESBURG OH 44688 3308663435
d.City(TOmm a State f.Zip Code g.Teleptwrre
D. Certification
PATRICKSENNOTT PATRKXSENNOTT
"I certify that I have personally 1.Name Z.Authorized Signature
examined the foregoing and am PRESIDENT 9128W17
familiar with the information
Notcontained in this document and 3'PosNor�tle 4.Dale(MWDDIYYYY)
sign t is form Ter must 9786837767
sign this form for Dts all attachments and that,based SENGIM,INC.
notification purposes on my inquiry of those 5.Telephone 6.Representing
individuals immediately 741 SOUTH MAIN STREET HAVERHILL
responsible for obtaining the 7,Address 8.City/Twm
information,1 believe that the MA 01835
information is true,accurate,and 9 Storm
complete.I am aware that there 10.Zip Code
are significant penalties for
submitting false information,
including possible fines and
imprisonment.The undersigned i
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: 11l13l2013 -- -- Page 4 of 4
Envir®-Safe Engineering
203 Prospect Street
Brockton, MA 02301
(69 7)623-6678
October 18,2017
Sen Cam
145 Marston St.
Lawrence, MA 01841
RE:Visual inspection, 1 1 Goodhue Street,Salem,MA
On October 16,2017,Dexter Wangnoon, Massachusetts licensed asbestos abatement project
monitor AM900511, conducted a final visual inspection of the removal of asbestos
containing roofing material at the above address.
No visible debris was observed as required by the US Environmental Protection Agency and
the Massachusetts Department of Labor Standards(DLS)..
If you have any questions or require additional information,please feel free to contact me at
(617)623-6678.
Sincerely,
Patricia E. Riley
President