HomeMy WebLinkAboutAsbestos Abatement - 2025Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
100435117
9ct zu20?5
HEALTH DEPTA. Asbestos Abatement Description
L Facility Location:
DONAIS 21 TRUMAN LANE
a. Name of Facility
YARMOUTH
b. Street Address
02673 0000000000MA
c. City/Town
X
d. State e. Zip Code
x
f. Telephone
lnstructions '1. All
sections of this form
must be completed in
order to comply with
MassDEP notificaion
requirements of 3'10
CMR 7.15 and
Department of Labor
Standards (DLS)
notification
requirements of 453
cMR6.12
MassDEP Use Only
Date Received
9. Facilaty Contracl Person Name
Worksite Location:
h. Facilily Contact Person Title
EASEI\4ENT
i. Building Name, Wing, Floor, Room, etc.
2. ls the facility occupied? F a. ves l- o. tto
3. ls this a fee exempt notification (city, town, district, municipal housing authority, state facility, or
owner-occupied residential property offour units or less)? F a. yes l- b. No
4. Blankct Permit Project Approval, ifapplicable:
Approval lD #
5. Non-Traditional Asbestos Abatement Work Practice Approval,
ifapplicable:Approval lD #
6. Asbestos Contractor:
NEW ENGTAND SURFACE MAIN'IENANCE LTP B5O WASHINGTON ST
a. Name
!VE/MOUIH
b. Address
02189t\,4A
c. City/Town
ACo00196
7413372117
d. State e. Zip Code I Telephone
h. Contract Type: F l. Written l- 2. Verbal
1
8
a. Name ol Contractor's On-Site Supervisor/Foreman b. DLS Certiication #
9
a. Name of Project Monitor b. DLS Certifcation #
N/A
A,Name of Asbestos Analytical Lab b DLS Certifcation #
10
10/30t2025 10t30t2025
a.Project Siart Date (N,iWDD^/)^/YJ b. End Date (MM/DD,ryyyy)
N/A7-3
urs - Monday Ihrough Friday d. Work Hours-Saturday&Sunday
I l. What type ofproject is this?
l- a. Demolition l- b. Renovation l- c. Repair p d. Other - please Speci!: ENOqPSULAIO|\
Revised: I l/13/2013
Page I of4
Asbestos Project #
I Prorcct Revlsron
j r-EEohe.Qa&Btatio{
I
9. DLS License #
JOSE VILT-ALTA AS061825
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-00I)
Asbestos Notifi cation Form
t00435 I l7
Asbestos Project #
f Project Revision
l- Project Cancellation
A. Asbestos Abatement Description: (cont.)
12. Abatement procedures (check all that apply):
l- a. Glove Bag |7 b. Encapsulation l- c. Enclosure l- d. Disposal Only l- e. Cleanup
F f. Full Containment l- g. Other - Please Specify:
13. Job is being conducted: F a. Indoors l- b. Outdoors
l4 a. Total amount of each qpe of asbestos Containing materials (ACM) to be removed, enclosed, or
encapsulated:
100
1. Linear Feet (Lin. Ft.)
b. Boiler, Breaching, Duct,
Tank Suface Coatings
d. Pipe tnsulation
f. Spray-On Fireproofing
h. Cloths, Woven Fabrics
j. lnsulating Cement
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
e. Transite Shingles
g. Transitc Pancls
i. Other - Pleasc Specify
1. Lin. Ft. 2. Sq. Ft
1. Lin. Ft. 2. Sq. Ft
1. Lin. Ft. 2. Sq. Ft
1. Lin. Ft.
'100
2. Sq. Ft.
'1. Lin. Ft. 2. Sq. Ft.1. Lin. Ft. 2. Sq. Ft.
15. Describe the decontamination system(s) to be used
AS REOUIRED
16. Describe the containerization/disposal methods to comply with 310 cMR 7. l5 and 453 cMR 6. l4(2)(s)
AS REOUIRED
lT For Emcrgency Asbestos opcrations, the MassDEP and DLS officials who evaluated the emergency
a. Name of MassDEp Official b. Title of MassDEp Officiat
c. Date ofAuthorization (MM/DD,^/yyy)
e. Name of DLS Officiat f. Title oF DLS Offlcial
g. Date of Authorization (M[.4/DD/yyyy)h. Waiver #
18..Do prevailing wage rates as per M.G.L. c. 149, g26,27 or 27A_F apply to this I- a. yes F b. Noproiect?
Revised: I I lt1l2O11
Pase 2 of 4
2. Square Feet (Sq. Ft.)
c. Transite Pipe
Massachusetts Department of Environmental Protection 1004351 l7BWP AQ 04 (ANF-001)Asbestos Project #
f Project Revision
I- Project Cancellation
Asbestos Notification Form
B. Facility Description
L Currcnt or prior use of facility
2. Is the facility owner-occupied residential with 4 units or less'l 17 a. Yes T b. No
DONAIS 21 TRUI\,4AN LANE
FESDEA1CE
a. Facility Owner Name
W€ST YARMOUTH
b. Address
02673 0000000000MA
c. City/Town d. Siate e. Zip Code f. Telephone
XX4a. Name of Facrlity Owner's On-Site Manager
X t\,1A
b. Address
00000 0000000000
c. City/Town d. State e. Zip Code f. Telephone
X X)a. Name ol General Contractor b. Address
00000MA 0000000000X
c. City/Town
X
d. State e. Zip Code f. Telephone
g. Contractor's Worke/s Compensation lnsurer
X 111i2026
h. Policy #i. Expiration Date (MM/DD^,WI
Notel Temporary
storage of Asbeslos
containing wasle
material is only
allowed at the place
of business of a DLS
liconsed Asbestos
contraclor or a transfer
station thal is
permitted by
MassDEP and
operated in
compliance with Sotid
waste R€gulations
310 Cr\4R 19.000
6. What is the size of this facility?2
a. Square Feet b. # of Floors
C. Asbestos Transportation & Disposal
L Transporter of asbestos-containing wastc material from site ofgeneration:
l- a. Directly to Landfill or 17 b. To Temporary Storagc Location/Transfer Station
NEW ENGLAND SURFACE MAINIENANCE, LLP 1 426 BEDFORD STREET
c. Name of Transporter
ABINGTON t\,4A
d. Address
023s1 7813372117
e. City/Town f. State g. Zip Code h. Telephone
2 lf a temporary storage location/transfer station is used, list name oftransporter ofasbestos containingwaste matcrial from temporary storagc location/transfer station to final disposal site:
RED TECHNOLOGIES
1 73 PICKERING SIREET
a- Name of Transporter
PORTI,AND CT 06480 8603421022c. City/Town d
Reviscd: I l/13/2013
Slate e. Zip Code f. Telephone
Pagc 3 of 4
1400
b. Address
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
100435 r 17
Asbestos Project #
[- Prqect Revision
l- Project Cancellation
C. Asbestos Transportation & Disposal: (cont.)
3. Name and address oftemporary storage location/transfer station for the asbestos containing waste
material:
REDTECIIIIOLOGIES ,173 PICKERII{G SIREET
a. Temporary Storage Location Name
PORTI.AND
b. Address
06480CT 8603421022
c. City/Town d. State e. Zip Code i Telephone
4. Name and location offinal disposal site (asbestos landfill):
MINER,/A ENTERPFISES I\4INERVA
a. F nal Disposal Sile Name
8955 MINERVA ROAD
b. Frnal Disposal Site Owner Name
c. Address
WAYNESBURG ctl 44688 330866343s
Noto: Contractor musl
sign this form for DLS
notification purposes
d. City/Town
D. Certification
"l 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 obtainlng the
information, I believe that the
information is true, accurale, and
complete. I am aware that there
are significant penalties for
submitting false information,
including possible fines and
imprisonmenl. 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 Cl\,lR 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.,,
e. State f. Zip Code g. Ietephone
SCOTT I\,ICXENNIA SCOTT I,4CKENNA
1. Narne
OIANER
2. Authorized Signature
'tol17t202s
3. Positiorl/Tite
7813372117
4. Dale (M [.l/DD/rYrY)
NESI\,4, LLP
5. Telephone
850 WASHINGTON SIREEI
7. Address 8. City/Town
02189
'10. Zip Code
Revised: l1l13/201i
Paee 4 of4
6. Representing
r /EYI\rqJIH
9. State