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Home My WebLink AboutANF 189 SILVERLEAF LANEMassachusetts Department of Environmental Protection eDEP Transaction Copy Here is the file you requested for your records. To retain a copy of this file you must save and/or print. Username: Transaction ID: Document: Size of File: Status of Transaction: Date and Time Created: Note: This file only includes forms that were part of your transaction as of the date and time indicated above. If you need a more current copy of your transaction, return to eDEP and select to “Download a Copy” from the Current Submittals page. 997828 3/28/2018:12:02:33 PM 236.04K NANCYT AQ 04 - Asbestos Removal Notification Form ANF-001 Submitted 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: 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 4 of 4 Massachusetts Department of Environmental Protection BWP AQ 04 (ANF001) Asbestos Notification Form 100282283 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 2. Submit Original Form To: Commonwealth of Massachusetts P.O. Box 4062 Boston, MA 02211 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: JANICE VANDERAA 189 SILVERLEAF LANE a. Name of Facility b. Street Address YARMOUTH MA 02673 9786215231 c. City/Town d. State e. Zip Code f. Telephone J VANDERAA OWNER g. Facility Contact Person Name h. Facility Contact Person Title Worksite Location:ATTIC i. Building Name, Wing, Floor, Room, etc. 2. Is the facility occupied?a. Yes b. No 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owneroccupied residential property of four units or less)?a. Yes b. No 4. Blanket Permit Project Approval, if applicable: Approval ID # 5. NonTraditional Asbestos Abatement Work Practice Approval, if applicable:Approval ID # 6. Asbestos Contractor: AIR SAFE INC 22 WILLOW STREET a. Name b. Address CHELSEA MA 02150 9783395361 c. City/Town d. State e. Zip Code f. Telephone AC000464 h. Contract Type:1. Written 2. Verbal g. DLS License # 7.ORLANDO MOLINA AS901826 a. Name of Contractor's OnSite Supervisor/Foreman b. DLS Certification # 8.KATTIA LOPEZ AM900491 a. Name of Project Monitor b. DLS Certification # 9.ASBESTOS IDENTIFICATION LAB AA000208 a. Name of Asbestos Analytical Lab b. DLS Certification # 10. 4/2/2018 4/5/2018 a. Project Start Date (MM/DD/YYYY)b. End Date (MM/DD/YYYY) 7AM 6PM NA c. Work Hours Monday Through Friday d. Work Hours Saturday & Sunday Revised: 11/13/2013 Page 1 of 4 A. Asbestos Abatement Description: (cont.) 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 b. Outdoors 14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or encapsulated: 800 1. Linear Feet (Lin. Ft.)2. Square Feet (Sq. Ft.) 15. Describe the decontamination system(s) to be used: 3 CHAMBER DECON 16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): 6 MIL POLY BAGS 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 project? a. Yes b. No Revised: 11/13/2013 Page 2 of 4 11. What type of project is this? a. Demolition b. Renovation c. Repair d. Other Please Specify: B. Facility Description 1. Current or prior use of facility:RESIDENTIAL 2. Is the facility owneroccupied residential with 4 units or less?a. Yes b. No 3.J VANDERAA 189 SILVERLEAF LANE a. Facility Owner Name b. Address YARMOUTH MA 02673 9786215231 c. City/Town d. State e. Zip Code f. Telephone 4.J VANDERAA 189 SILVERLEAF LANE a. Name of Facility Owner's OnSite Manager b. Address YARMOUTH MA 02673 9786215231 c. City/Town d. State e. Zip Code f. Telephone 5.NA NA a. Name of General Contractor b. Address NA MA 02673 1111111111 c. City/Town d. State e. Zip Code f. Telephone NA g. Contractor's Worker's Compensation Insurer NA 12/31/2018 h. Policy #i. Expiration Date (MM/DD/YYYY) 6. What is the size of this facility?800 2 a. Square Feet b. # of Floors Revised: 11/13/2013 Page 3 of 4 C. Asbestos Transportation & Disposal 1. Transporter of asbestoscontaining waste material from site of generation: a. Directly to Landfill or b. To Temporary Storage Location/Transfer Station AIR SAFE INC 22 WILLOW ST c. Name of Transporter d. Address CHELSEA MA 02150 9783395361 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: SERVICE TRANS GROUP 58 PYLES LANE a. Name of Transporter b. Address NEW CASTLE DE 19720 8779999559 c. City/Town d. State e. Zip Code f. Telephone C. Asbestos Transportation & Disposal: (cont.) 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material: AIR SAFE INC 22 WILLOW ST a. Temporary Storage Location Name b. Address CHELSEA MA 0215 9783395361 c. City/Town d. State e. Zip Code f. Telephone 4. Name and location of final disposal site (asbestos landfill): MINERVA LANDFILL MINERVA ENTERPRISES, INC a. Final Disposal Site Name b. Final Disposal Site Owner Name 9000 MINERVA RD c. Address WAYNESBURG OH 44688 3308663435 d. City/Town e. State f. Zip Code g. Telephone b. Boiler, Breaching, Duct, Tank Surface Coatings 1. Lin. Ft.2. Sq. Ft. d. Pipe Insulation 1. Lin. Ft.2. Sq. Ft. f. SprayOn Fireproofing 1. Lin. Ft.2. Sq. Ft. h. Cloths, Woven Fabrics 1. Lin. Ft.2. Sq. Ft. j. Insulating Cement 1. Lin. Ft.2. Sq. Ft. c. Transite Pipe 1. Lin. Ft.2. Sq. Ft. e. Transite Shingles 1. Lin. Ft.2. Sq. Ft. g. Transite Panels 1. Lin. Ft.2. Sq. Ft. i. Other Please Specify: VERMICULITE 1. Lin. Ft. 800 2. Sq. Ft. D. 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." DFW 1. Name PRES 3. Position/Title 9783395361 5. Telephone 23 WYCHWOOD DR 7. Address MA 9. State DFW 2. Authorized Signature 3/5/2018 4. Date (MM/DD/YYYY) AIR SAFE, INC 6. Representing LITTLETON 8. City/Town 01460 10. Zip Code Revised: 11/13/2013 Page 4 of 4 Massachusetts Department of Environmental ProtectionBWP AQ 04 (ANF001)Asbestos Notification Form 100282283Asbestos 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 Received2. Submit OriginalForm To:Commonwealth ofMassachusettsP.O. Box 4062Boston, MA 02211 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 Description1. Facility Location:JANICE VANDERAA 189 SILVERLEAF LANEa. Name of Facility b. Street AddressYARMOUTHMA02673 9786215231c. City/Town d. State e. Zip Code f. TelephoneJ VANDERAA OWNERg. Facility Contact Person Name h. Facility Contact Person TitleWorksite Location:ATTICi. Building Name, Wing, Floor, Room, etc.2. Is the facility occupied?a. Yes b. No3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, orowneroccupied residential property of four units or less)?a. Yes b. No4. Blanket Permit Project Approval, if applicable:Approval ID #5. NonTraditional Asbestos Abatement Work Practice Approval,if applicable:Approval ID #6. Asbestos Contractor:AIR SAFE INC 22 WILLOW STREETa. Name b. AddressCHELSEAMA02150 9783395361c. City/Town d. State e. Zip Code f. TelephoneAC000464h. Contract Type:1. Written 2. Verbalg. DLS License #7.ORLANDO MOLINA AS901826a. Name of Contractor's OnSite Supervisor/Foreman b. DLS Certification #8.KATTIA LOPEZ AM900491a. Name of Project Monitor b. DLS Certification #9.ASBESTOS IDENTIFICATION LAB AA000208a. Name of Asbestos Analytical Lab b. DLS Certification #10.4/2/2018 4/5/2018a. Project Start Date (MM/DD/YYYY)b. End Date (MM/DD/YYYY)7AM 6PM NA c. Work Hours Monday Through Friday d. Work Hours Saturday & Sunday Revised: 11/13/2013 Page 1 of 4 A. Asbestos Abatement Description: (cont.) 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 b. Outdoors 14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or encapsulated: 800 1. Linear Feet (Lin. Ft.)2. Square Feet (Sq. Ft.) 15. Describe the decontamination system(s) to be used: 3 CHAMBER DECON 16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): 6 MIL POLY BAGS 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 project? a. Yes b. No Revised: 11/13/2013 Page 2 of 4 11. What type of project is this? a. Demolition b. Renovation c. Repair d. Other Please Specify: B. Facility Description 1. Current or prior use of facility:RESIDENTIAL 2. Is the facility owneroccupied residential with 4 units or less?a. Yes b. No 3.J VANDERAA 189 SILVERLEAF LANE a. Facility Owner Name b. Address YARMOUTH MA 02673 9786215231 c. City/Town d. State e. Zip Code f. Telephone 4.J VANDERAA 189 SILVERLEAF LANE a. Name of Facility Owner's OnSite Manager b. Address YARMOUTH MA 02673 9786215231 c. City/Town d. State e. Zip Code f. Telephone 5.NA NA a. Name of General Contractor b. Address NA MA 02673 1111111111 c. City/Town d. State e. Zip Code f. Telephone NA g. Contractor's Worker's Compensation Insurer NA 12/31/2018 h. Policy #i. Expiration Date (MM/DD/YYYY) 6. What is the size of this facility?800 2 a. Square Feet b. # of Floors Revised: 11/13/2013 Page 3 of 4 C. Asbestos Transportation & Disposal 1. Transporter of asbestoscontaining waste material from site of generation: a. Directly to Landfill or b. To Temporary Storage Location/Transfer Station AIR SAFE INC 22 WILLOW ST c. Name of Transporter d. Address CHELSEA MA 02150 9783395361 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: SERVICE TRANS GROUP 58 PYLES LANE a. Name of Transporter b. Address NEW CASTLE DE 19720 8779999559 c. City/Town d. State e. Zip Code f. Telephone C. Asbestos Transportation & Disposal: (cont.) 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material: AIR SAFE INC 22 WILLOW ST a. Temporary Storage Location Name b. Address CHELSEA MA 0215 9783395361 c. City/Town d. State e. Zip Code f. Telephone 4. Name and location of final disposal site (asbestos landfill): MINERVA LANDFILL MINERVA ENTERPRISES, INC a. Final Disposal Site Name b. Final Disposal Site Owner Name 9000 MINERVA RD c. Address WAYNESBURG OH 44688 3308663435 d. City/Town e. State f. Zip Code g. Telephone b. Boiler, Breaching, Duct, Tank Surface Coatings 1. Lin. Ft.2. Sq. Ft. d. Pipe Insulation 1. Lin. Ft.2. Sq. Ft. f. SprayOn Fireproofing 1. Lin. Ft.2. Sq. Ft. h. Cloths, Woven Fabrics 1. Lin. Ft.2. Sq. Ft. j. Insulating Cement 1. Lin. Ft.2. Sq. Ft. c. Transite Pipe 1. Lin. Ft.2. Sq. Ft. e. Transite Shingles 1. Lin. Ft.2. Sq. Ft. g. Transite Panels 1. Lin. Ft.2. Sq. Ft. i. Other Please Specify: VERMICULITE 1. Lin. Ft. 800 2. Sq. Ft. D. 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." DFW 1. Name PRES 3. Position/Title 9783395361 5. Telephone 23 WYCHWOOD DR 7. Address MA 9. State DFW 2. Authorized Signature 3/5/2018 4. Date (MM/DD/YYYY) AIR SAFE, INC 6. Representing LITTLETON 8. City/Town 01460 10. Zip Code Massachusetts Department of Environmental Protection BWP AQ 04 (ANF001) Asbestos Notification Form 100282283 Asbestos Project # Project Revision Project Cancellation Revised: 11/13/2013 Page 4 of 4 Massachusetts Department of Environmental ProtectionBWP AQ 04 (ANF001)Asbestos Notification Form 100282283Asbestos 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 Received2. Submit OriginalForm To:Commonwealth ofMassachusettsP.O. Box 4062Boston, MA 02211 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 Description1. Facility Location:JANICE VANDERAA 189 SILVERLEAF LANEa. Name of Facility b. Street AddressYARMOUTHMA02673 9786215231c. City/Town d. State e. Zip Code f. TelephoneJ VANDERAA OWNERg. Facility Contact Person Name h. Facility Contact Person TitleWorksite Location:ATTICi. Building Name, Wing, Floor, Room, etc.2. Is the facility occupied?a. Yes b. No3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, orowneroccupied residential property of four units or less)?a. Yes b. No4. Blanket Permit Project Approval, if applicable:Approval ID #5. NonTraditional Asbestos Abatement Work Practice Approval,if applicable:Approval ID #6. Asbestos Contractor:AIR SAFE INC 22 WILLOW STREETa. Name b. AddressCHELSEAMA02150 9783395361c. City/Town d. State e. Zip Code f. TelephoneAC000464h. Contract Type:1. Written 2. Verbalg. DLS License #7.ORLANDO MOLINA AS901826a. Name of Contractor's OnSite Supervisor/Foreman b. DLS Certification #8.KATTIA LOPEZ AM900491a. Name of Project Monitor b. DLS Certification #9.ASBESTOS IDENTIFICATION LAB AA000208a. Name of Asbestos Analytical Lab b. DLS Certification #10.4/2/2018 4/5/2018a. Project Start Date (MM/DD/YYYY)b. End Date (MM/DD/YYYY)7AM 6PM NAc. Work Hours Monday Through Friday d. Work Hours Saturday & SundayRevised: 11/13/2013 Page 1 of 4A. Asbestos Abatement Description: (cont.)12. Abatement procedures (check all that apply):a. Glove Bag b. Encapsulation c. Enclosure d. Disposal Only e. Cleanupf. Full Containment g. Other Please Specify:13. Job is being conducted:a. Indoors b. Outdoors14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, orencapsulated:8001. Linear Feet (Lin. Ft.)2. Square Feet (Sq. Ft.)15. Describe the decontamination system(s) to be used:3 CHAMBER DECON16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g):6 MIL POLY BAGS17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency:a. Name of MassDEP Official b. Title of MassDEP Officialc. 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 project? a. Yes b. No Revised: 11/13/2013 Page 2 of 4 11. What type of project is this?a. Demolition b. Renovation c. Repair d. Other Please Specify: B. Facility Description 1. Current or prior use of facility:RESIDENTIAL 2. Is the facility owneroccupied residential with 4 units or less?a. Yes b. No 3.J VANDERAA 189 SILVERLEAF LANE a. Facility Owner Name b. Address YARMOUTH MA 02673 9786215231 c. City/Town d. State e. Zip Code f. Telephone 4.J VANDERAA 189 SILVERLEAF LANE a. Name of Facility Owner's OnSite Manager b. Address YARMOUTH MA 02673 9786215231 c. City/Town d. State e. Zip Code f. Telephone 5.NA NA a. Name of General Contractor b. Address NA MA 02673 1111111111 c. City/Town d. State e. Zip Code f. Telephone NA g. Contractor's Worker's Compensation Insurer NA 12/31/2018 h. Policy #i. Expiration Date (MM/DD/YYYY) 6. What is the size of this facility?800 2 a. Square Feet b. # of Floors Revised: 11/13/2013 Page 3 of 4 C. Asbestos Transportation & Disposal 1. Transporter of asbestoscontaining waste material from site of generation: a. Directly to Landfill or b. To Temporary Storage Location/Transfer Station AIR SAFE INC 22 WILLOW ST c. Name of Transporter d. Address CHELSEA MA 02150 9783395361 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: SERVICE TRANS GROUP 58 PYLES LANE a. Name of Transporter b. Address NEW CASTLE DE 19720 8779999559 c. City/Town d. State e. Zip Code f. Telephone C. Asbestos Transportation & Disposal: (cont.) 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material: AIR SAFE INC 22 WILLOW ST a. Temporary Storage Location Name b. Address CHELSEA MA 0215 9783395361 c. City/Town d. State e. Zip Code f. Telephone 4. Name and location of final disposal site (asbestos landfill): MINERVA LANDFILL MINERVA ENTERPRISES, INC a. Final Disposal Site Name b. Final Disposal Site Owner Name 9000 MINERVA RD c. Address WAYNESBURG OH 44688 3308663435 d. City/Town e. State f. Zip Code g. Telephone b. Boiler, Breaching, Duct,Tank Surface Coatings 1. Lin. Ft.2. Sq. Ft.d. Pipe Insulation 1. Lin. Ft.2. Sq. Ft.f. SprayOn Fireproofing 1. Lin. Ft.2. Sq. Ft.h. Cloths, Woven Fabrics 1. Lin. Ft.2. Sq. Ft.j. Insulating Cement 1. Lin. Ft.2. Sq. Ft.c. Transite Pipe 1. Lin. Ft.2. Sq. Ft.e. Transite Shingles 1. Lin. Ft.2. Sq. Ft.g. Transite Panels 1. Lin. Ft.2. Sq. Ft.i. Other Please Specify:VERMICULITE 1. Lin. Ft.8002. Sq. Ft. D. 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." DFW 1. Name PRES 3. Position/Title 9783395361 5. Telephone 23 WYCHWOOD DR 7. Address MA 9. State DFW 2. Authorized Signature 3/5/2018 4. Date (MM/DD/YYYY) AIR SAFE, INC 6. Representing LITTLETON 8. City/Town 01460 10. Zip Code Massachusetts Department of Environmental Protection BWP AQ 04 (ANF001) Asbestos Notification Form 100282283 Asbestos Project # Project Revision Project Cancellation Revised: 11/13/2013 Page 4 of 4 Massachusetts Department of Environmental ProtectionBWP AQ 04 (ANF001)Asbestos Notification Form 100282283Asbestos 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 Received2. Submit OriginalForm To:Commonwealth ofMassachusettsP.O. Box 4062Boston, MA 02211Note: Temporarystorage of Asbestoscontaining wastematerial is onlyallowed at the placeof business of a DLSlicensed Asbestoscontractor or a transferstation that ispermitted byMassDEP 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 Description1. Facility Location:JANICE VANDERAA 189 SILVERLEAF LANEa. Name of Facility b. Street AddressYARMOUTHMA02673 9786215231c. City/Town d. State e. Zip Code f. TelephoneJ VANDERAA OWNERg. Facility Contact Person Name h. Facility Contact Person TitleWorksite Location:ATTICi. Building Name, Wing, Floor, Room, etc.2. Is the facility occupied?a. Yes b. No3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, orowneroccupied residential property of four units or less)?a. Yes b. No4. Blanket Permit Project Approval, if applicable:Approval ID #5. NonTraditional Asbestos Abatement Work Practice Approval,if applicable:Approval ID #6. Asbestos Contractor:AIR SAFE INC 22 WILLOW STREETa. Name b. AddressCHELSEAMA02150 9783395361c. City/Town d. State e. Zip Code f. TelephoneAC000464h. Contract Type:1. Written 2. Verbalg. DLS License #7.ORLANDO MOLINA AS901826a. Name of Contractor's OnSite Supervisor/Foreman b. DLS Certification #8.KATTIA LOPEZ AM900491a. Name of Project Monitor b. DLS Certification #9.ASBESTOS IDENTIFICATION LAB AA000208a. Name of Asbestos Analytical Lab b. DLS Certification #10.4/2/2018 4/5/2018a. Project Start Date (MM/DD/YYYY)b. End Date (MM/DD/YYYY)7AM 6PM NAc. Work Hours Monday Through Friday d. Work Hours Saturday & SundayRevised: 11/13/2013 Page 1 of 4A. Asbestos Abatement Description: (cont.)12. Abatement procedures (check all that apply):a. Glove Bag b. Encapsulation c. Enclosure d. Disposal Only e. Cleanupf. Full Containment g. Other Please Specify:13. Job is being conducted:a. Indoors b. Outdoors14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, orencapsulated:8001. Linear Feet (Lin. Ft.)2. Square Feet (Sq. Ft.)15. Describe the decontamination system(s) to be used:3 CHAMBER DECON16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g):6 MIL POLY BAGS17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency:a. Name of MassDEP Official b. Title of MassDEP Officialc. Date of Authorization (MM/DD/YYYY)d. Waiver #e. Name of DLS Official f. Title of DLS Officialg. 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 thisproject?a. Yes b. NoRevised: 11/13/2013 Page 2 of 411. What type of project is this?a. Demolition b. Renovation c. Repair d. Other Please Specify:B. Facility Description1. Current or prior use of facility:RESIDENTIAL2. Is the facility owneroccupied residential with 4 units or less?a. Yes b. No3.J VANDERAA 189 SILVERLEAF LANEa. Facility Owner Name b. AddressYARMOUTHMA02673 9786215231c. City/Town d. State e. Zip Code f. Telephone4.J VANDERAA 189 SILVERLEAF LANEa. Name of Facility Owner's OnSite Manager b. AddressYARMOUTHMA02673 9786215231c. City/Town d. State e. Zip Code f. Telephone5.NA NAa. Name of General Contractor b. AddressNAMA02673 1111111111c. City/Town d. State e. Zip Code f. TelephoneNAg. Contractor's Worker's Compensation InsurerNA 12/31/2018h. Policy #i. Expiration Date (MM/DD/YYYY)6. What is the size of this facility?800 2a. Square Feet b. # of Floors Revised: 11/13/2013 Page 3 of 4 C. Asbestos Transportation & Disposal1. Transporter of asbestoscontaining waste material from site of generation:a. Directly to Landfill or b. To Temporary Storage Location/Transfer StationAIR SAFE INC 22 WILLOW STc. Name of Transporter d. AddressCHELSEAMA02150 9783395361e. City/Town f. State g. Zip Code h. Telephone2. If a temporary storage location/transfer station is used, list name of transporter of asbestos containingwaste material from temporary storage location/transfer station to final disposal site:SERVICE TRANS GROUP 58 PYLES LANEa. Name of Transporter b. Address NEW CASTLE DE 19720 8779999559 c. City/Town d. State e. Zip Code f. Telephone C. Asbestos Transportation & Disposal: (cont.) 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material: AIR SAFE INC 22 WILLOW ST a. Temporary Storage Location Name b. Address CHELSEA MA 0215 9783395361 c. City/Town d. State e. Zip Code f. Telephone 4. Name and location of final disposal site (asbestos landfill): MINERVA LANDFILL MINERVA ENTERPRISES, INC a. Final Disposal Site Name b. Final Disposal Site Owner Name 9000 MINERVA RD c. Address WAYNESBURG OH 44688 3308663435 d. City/Town e. State f. Zip Code g. Telephone b. Boiler, Breaching, Duct,Tank Surface Coatings 1. Lin. Ft.2. Sq. Ft.d. Pipe Insulation 1. Lin. Ft.2. Sq. Ft.f. SprayOn Fireproofing 1. Lin. Ft.2. Sq. Ft.h. Cloths, Woven Fabrics 1. Lin. Ft.2. Sq. Ft.j. Insulating Cement 1. Lin. Ft.2. Sq. Ft.c. Transite Pipe 1. Lin. Ft.2. Sq. Ft.e. Transite Shingles 1. Lin. Ft.2. Sq. Ft.g. Transite Panels 1. Lin. Ft.2. Sq. Ft.i. Other Please Specify:VERMICULITE 1. Lin. Ft.8002. Sq. Ft. D. 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." DFW 1. Name PRES 3. Position/Title 9783395361 5. Telephone 23 WYCHWOOD DR 7. Address MA 9. State DFW 2. Authorized Signature 3/5/2018 4. Date (MM/DD/YYYY) AIR SAFE, INC 6. Representing LITTLETON 8. City/Town 01460 10. Zip Code Massachusetts Department of Environmental Protection BWP AQ 04 (ANF001) Asbestos Notification Form 100282283 Asbestos Project # Project Revision Project Cancellation