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Home My WebLink About2024 Asbestos Notification Form Massachusetts Department of Environmental Protection 100412935 BWP AQ 04 (ANF-001) Asbestos Project # ' Asbestos Notification Form r Project Revision r Project Cancellation A. Asbestos Abatement Description 1. Facility Location: DOLAN 214 MAIN STREET Instructions 1.All a.Name of Facility b.Street Address sections of this form YARMOUTH must be completed in MA 02675 0000000000 order to comply with c.City/Town 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: ATTIC Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc. requirements of 453 2. Is the facility occupied? 17 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)? Pi a.Yes Ir b. No MassDEP Use Only 4. Blanket Permit Project Approval, if applicable: Date Received Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: Approval ID# �t 6. Asbestos Contractor: W _ NEW ENGLAND SURFACE MAINTENANCE LLP 850 WASHINGTON ST (V p_ J a.Name b.Address a WEYMOUTH MA 02189 7813372117 = c.City/Town d.State e.Zip Code f.Telephone AC000196 h. Contract Type: r 1.Written r 2.Verbal g.DLS License# JOSE VILLALTA AS061825 7. 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. IU G k 11/18/2024 11/18/2024 CV Q a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) rum ci' 0 O X 8-4 N/A Liu W a c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday Z 11. What type of project is this? r a. Demolition r b.Renovation r c. Repair r d. Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 ? Massachusetts Department of Environmental Protection 100412935 - BWP AQ 04 (ANF-001) Asbestos Notification Form Asbestos Project # ✓ Project Revision ✓ Project Cancellation A. Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): ✓ a.Glove Bag r b.Encapsulation r c. Enclosure r d.Disposal Only r e.Cleanup ✓ f.Full Containment r g. Other-Please Specify: 13. Job is being conducted: r a. Indoors r b. Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 0 1000 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b. Boiler,Breaching,Duct, c. Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.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 1000 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 r a. Yes r b. No project? Revised: 11/13/2013 Paf>e 2 nf4 Massachusetts Department of Environmental Protection i 100412935 BWP AQ 04 (ANF-001) Asbestos Project # N. Asbestos Notification Form r Project Revision r Project Cancellation B. Facility Description RESIDENCE 1. Current or prior use of facility: 2. Is the facility owner-occupied residential with 4 units or less? r a.Yes r b. No 3 DOLAN 214 MAIN STREET a.Facility Owner Name b.Address YARMOUTH PORT MA 02675 000000000 c.City/Town d.State e.Zip Code f.Telephone 4 X 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 0000000000 c.City/Town d.State e.Zip Code f.Telephone X g.Contractor's Worker's Compensation Insurer X 1/1/2025 h.Policy# i.Expiration Date(MM/DD/YYYY) 1400 2 6. What is the size of this facility? a.Square Feet b.#of Floors Note:Temporary C. Asbestos Transportation & Disposal storage of Asbestos p p containing waste 1. Transporter of asbestos-containing waste material from site of generation: material is only allowed at the place r a. Directly to Landfill or h+ b. To Temporary Storage Location/Transfer Station of business of a DLS licensed Asbestos contractor or a transfer NEW ENGLAND SURFACE MAINTENANCE,LLP 850 WASHINGTON STREET station that is c.Name of Transporter d.Address permitted by MassDEP and WEYMOUTH MA 02189 7813372117 operated in e.City/Town f.State g.Zip Code h.Telephone compliance with Solid Waste Regulations 310 CMR 19.000 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 8603421022 c.City/Town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 Massachusetts Department of Environmental Protection 100412935 Lai BWP AQ 04 (ANF-001) Asbestos Project # Asbestos Notification Form r Project Revision r Project Cancellation C. Asbestos Transportation & Disposal: (cont.) 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material: RED TECHNOLOGIES 173 PICKERING STREET a.Temporary Storage Location Name b.Address PORTLAND CT 06480 8603421022 c.City/Town d.State e.Zip Code f.Telephone 4. Name and location of final disposal site(asbestos landfill): MINERVA ENTERPRISES MINERVA a.Final Disposal Site Name b.Final Disposal Site Owner Name 8955 MINERVA ROAD c.Address WAYNESBURG OH 44688 3308663435 d.City/Town e.State f.Zip Code g.Telephone Note:Contractor must sign this form for DLS notification purposes D. Certification KEN FURTNEY KEN FURTNEY "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PARTNER 9/6/2024 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) all attachments and that, based 7813372117 NESM,LLP on my inquiry of those 5.Telephone 6.Representing individuals immediately 850 WASHINGTON STREET WEYMOUTH responsible for obtaining the 7.Address 8.City/Town 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 Pace 4 of 4