33 LEACH STREET - ASBESTOS Massachusetts Department of Environmental Protection 100281387
BWP AQ 04 (ANF-001)
LL�7
Asbestos Project f!
Asbestos Notification Form
r Project Revision
r PR'tyi%ED
A. Asbestos Abatement Description FEB 2 0 2013
CITY OF 1.Facility Location: BOARD OF HEALTH
Sr.PIERRE 33 LEACH STREET
Instructions 1.Al a.Name of Facility b.Street Address
sections of this form SALEM MA 01970 0000000000
must be completed in _
order to comply with c.City/rown d.State e.Zip-Code f.Telephone
MassDEP notification x x
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.Building Name,Wing,Floor,Room,etc.
requirements of 453 2. Is the facility occupied? r a.Yes r 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)? r a.Yes r b.No
MassDEP Use Only
4.Blanket Permit Project Approval,if applicable:
Date Received Approval ID#
5.Non-Traditional Asbestos Abatement Work Practice Approval,
2.Submit Original if applicable: Approval ID#
Form To:
Commonwealth of
Massachusetts 6.Asbestos Contractor:
P.O.Box 4062
Boston, MA 02211 NEW ENGLAND SURFACE MAINTENANCE LLP 850WASHINGTONST
a.Name b.Address
WEYMOUTH MA 02189 7813372117
c.City?own d.State e.Zip Code f.Telephone
A0000196 h.Contract Type: G 1.Written r 2.Verbal
g.DLS License#
? JOHN P.VAL IQUETTE AS060773
a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification#
$ RICHARDK BOWEN AM061 D44
a.Name of Project Monitor b.DLS Certification#
9 FLI ENVIRONMENTAL INC AA000144
a.Name of Asbestos Analytical Lab b.DLS Certification#
10.
3/6/2018 3/6/2018
a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY)
7-4 N/A
c.Work Hours-Monday Through Friday d.Work Hours-Saturday 8 Sunday
11. What type of project is this?
r a.Demolition r b.Renovation I✓ c.Repair r d.Other-Please Specify:
Revised: 11/13/2013 Page I of 4
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001) Ioo2sl3s7
Asbestos Notification Form Asbestos Project#
_ r Project Revision
r Project Cancellation
EA.Asbestos Abatement Description: (cont.)
12.Abatement procedures(check all that apply): FEB 2 0 2018
r a.Glove Bag r b.Encapsulation r c.Enclosure r d.Disposal Only r e.Cleanu
r f.Full Containment r g. Other-Please Specify: BOA Y OF SALEM
13.Job is beingconducted: OF HEALTH
a. Indoors r b. Outdoors
14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:
25
1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.)
b.Boiler,Breaching,Duct,
Tank Surface Coatings 1.Lin.FL 2.Sq.Ft. C.Transite Pipe
d. Pipe Insulation 1.Lin.Ft. 2.Sq.Ft.
25 e.Transite Shingles
1.Lin.Ft. 2.Sq.Ft.
f. Spray-On Fireproofing 1.Lin.Ft. 2.Sq.Ft.
g. Transite Panels
1.Lin.FL 2.Sq.Ft
It.Cloths, Woven Fabrics 1.Lin,Ft. 2.Sq.Ft.
i.Other-Please Specify:
i.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:
AS REQUIRED
16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CM 6.14(2)
(g):
AS REQUIRED
17. For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: I
a.Name of MassDEP Official
b.Title of MassDEP Official
c.Date of Authonution(MM/DD/YYYY)
d.Waiver#
e.Name of DLS Official
f.Title of DLS Official
g.Date of Authonzabo—n(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 ry b. No
project?
Revised: 11/I3/2013
Page 2 of 4
Massachusetts Department of Environmental Protection L_- 100281387
BWP AQ 04 (ANF-001) Asbestos Project#
Asbestos Notification Form
r Project Revision
r Project Cancellation
RECEm1�1"ED
B. Facility Description FEB 2 0 2013
1.Current or prior use of facility: RESIDENCE
Y OF SALENI
2. Is the facility owner-occupied residential with 4 units or less? r a.Yes r b.No BOARD OF HEALTH
3 ST PIERRE 33 LEACH STREET
a.Facility Owner Name b.Address
SALEM MA 01970 0000000000
c.City/Town d.State e.Zip Code f.Telephone
4X X
a.Name of Facility Owner's On-Site Manager b.Address
X MA 00000 0000000000
c.City/Town d.State e.Zip Code f.Telephone
5 X X
a.Name of General Contractor b.Address
X MA 00000 000000000
c.City/Town d.State e.Zip Code f.Telephone
X
g.Contractor's Workers Compensation Insurer
X 1/1/2019
h.Policy# i.Expiration Date(MM/DDA'YYV)
6.What is the size of this facility? 1200 2
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 r b.To Temporary Storage Location/Transfer Station
NEWENGLAND SURFACE MAINTENANCELLP 850 WASHINGTON STREET
c.Name of Transporter d.Address
Note:Temporary
storage of Asbestos WEYMOUTH MA 02189 7813372117
containing waste e.City/Town f.State g.Zip Code h.Telephone
material is only
allowed at the place
of business of a DLS 2.If a temporary storage location/transfer station is used,list name of transporter of asbestos containing
licensed Asbestos
contractor or a transfer waste material from temporary storage location/transfer station to final disposal site:
c
station that is
permitted by REDTECHNOLOGIES 10NORTHWOODDRIVE
MassDEP and a.Name of Transporter b.Address
operated in
compliance with Solid BLOOMFIELD CT 06002 8602182428
Waste Regulations 310 CMR 19.000 c.City/Town d.State e.Zip Code I.Telephone
Revised: 11/13/2013 Page 3 of 4
Massachusetts Department of Environmental Protection 100281387
\7" BWP AQ 04 (ANF-001)
Asbestos Project#
;, Asbestos Notification Form r Project RREIVED
r Project Cancellation
FEB 2 8
C.Asbestos Transportation& Disposal: (coat.) CITY OF SALEM
3.Name and address of temporary storage location/transfer station for the asbestos containing WARD OF HEALTH
material:
RED TECHOLOGIES 203 PICKERING STREET
a.Temporary Storage Location Name b.Address
PORTLAND CT 06480 8603421022
c.City/rown d.State e.Zip Code I.Telephone
4.Name and location of final disposal site(asbestos landfill):
MINERVA ENTERPRISES MINERVA
a.Final Disposal Site Name b.Final Disposal She Owner Name
9000 MINERVA ROAD
c.Address
WAYNESBURG CH 44688 3308663435
d.City/Town e.State I.Zip Code g.Telephone
D. Certification
JIM DOYLE JIM DOYLE
"I certify that I have personally 1.Name 2.Authorized Signature
examined the foregoing and am PARTNER 2M6/2018
familiar with the information 3.Posltion/Tllle 4.Date(MM/DDNYYY)
Note:Contractor must contained in this document and
sign this form for DLS all attachments and that, based 7813372117 NESM,LLP
notification purposes on my inquiry of those 5.Telephone 6.Representing
individuals immediately 850 WASHINGTON STREET WEYMOUTH
responsible for obtaining the 7.Address 8.City/rown
information, I believe that the MA 02189
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