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Home My WebLink AboutAsbestos Notification Form LI1 Massachusetts Department of Environmental Protection 100397636 BWP AQ 04 (AN F-001) Asbestos Project# Asbestos Notification Form Project Revision Project Cancellation A. Asbestos Abatement Description 1. Facility Location: DEC i14 Z023 TAVARES 44 ALDEN ROAD a.Name of Facility b.Street Address - YARMOUTH v MA 02673 000-000-0000 c.City/Town d.State e.Zip Code f.Telephone X X 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 comply with MassDEP 2. Is the facility occupied? a.Yes 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 b.No Standards(DLS) notification requirements 4. Blanket Permit Project Approval, if applicable:PP PP L of 453 CMR 6.12 Approval ID# 5. Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: MassDEP Use Only Approval ID# 6.Asbestos Contractor: Date Received NEW ENGLAND SURFACE MAINTENANCE LLP i 850 WASHINGTON ST a.Name b.Address WEYMOUTH MA ' 02189 I 1781-337-2117 c.City/Town d.State e.Zip Code f.Telephone AC000196 ' h.Contract Type: 1.Written 2.Verball g.DLS License# 7. JOSE VILLALTA AS061825 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8. N/A a.Name of Project Monitor b.DLS Certification# 9. N/A a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 12/14/2023 j 12/14/2023 J a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 8-4PM N/A c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11. What type of project is this? a.Demolition b.Renovation 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 g.Other-Please Specify: 13. Job is being conducted: a.Indoors 1 b.Outdoors 14 a. Total amount of each type of asbestos Containing materials (ACM)to be removed, enclosed, or encapsulated: 140 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct,Tank l c.Transite Pipe Surface Coatings t i in 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 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 140 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: 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 I 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 b.No 3. LTAVARES 44 ALDEN ROAD a.Facility Owner Name b.Address WEST YARMOUTH LMA 02673 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 DEC n 4 2p3 HEALTH p_pr Note:Temporary storage X MA 00000 000-000-0000 of Asbestos containing P, C X X waste material is only a.Name of General Contractor b.Address allowed at the place of business of a DLS X -- MA 00000 {000-000-0000 ._.. licensed Asbestos c.City/Town d.State e.Zip Code f.Telephone contractor or a transfer X station that is permitted g.Contractor's Worker's Compensation Insurer by MassDEP and X 01/01/2024 operated in compliance h.Policy# i.Expiration Date(MM/DD/YYYY) with Solid Waste Regulations 310 CMR 6. What is the size of this facility? 1400 2 19.000 a.Square Feet b.#of Floors C. Asbestos Transportation & Disposal 1. Transporter of asbestos-containing waste material from site of generation: a.Directly to Landfill or b.To Temporary Storage Location/Transfer Station NEW ENGLAND SURFACE MAINTENANCE,LLP 850 WASHINGTON STREET c.Name of Transporter d.Address WEYMOUTH MA 02189 781-337-2117 e.City/Town f.State g.Zip Code h.Telephone 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 PORTLAND CT 06480 860-342-1022 c.City/Town d.State e.Zip Code f.Telephone Note:Contractor must sign this form for DLS 3. Name and address of temporary storage location/transfer station for the asbestos containing waste notification purposes material: RED TECHNOLOGIES L173 PICKERING STREET a Temnorarv.Storane I ncation.Name. a_Address PORLTAND 1 `CT 06480 1 [860-342-1022 c.City/Town d.State e.Zip Code f.Telephone 4. Name and location of final disposal site (asbestos landfill): MINERVA ENTERPRISES I MINERVA a.Final Disposal Site Name b.Final Disposal Site Owner Name 8955 MINERVA ROAD c.Address WAYNESBURG OH I 44688 330-866-3435 d.City/Town e.State f.Zip Code g.Telephone D. Certification "I certify that I have personally examined KEN FURTNEY KEN FURTNEY 1.Name 2.Authorized Signature the foregoingand am familiar with the information contained in this document rPARTNER 12/01/2023 and all attachments and that,based on 3.Position/Title 4.Date(MM/DD/YYYY) my inquiry of those individuals immediately responsible for obtaining 781-337-2117 NESM,LLP the information,I believe that the 5.Telephone 6.Representing information is true,accurate,and 850 WASHINGTON STREET WEYMOUTH complete.I am aware that there are 7.Address 8.City/Town significant penalties for submitting false MA 02189 information,including possible fines and imprisonment.The undersigned hereby 9.State 10.Zip Code 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 n �fL Department of Environmental UL Protection),and that I am aware that F DEPT.T. this permit application or notification shall not be deemed valid unless payment of the applicable fee is made."