560 Asbestos Notification Form 2014 2j::'4 "'"' Air Quality Experts, Inc. `� ��� �`��
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94-6465 Asbestos Removal
21-1189 23 Hall Farm Road Residential-Commercial-Industrial
94-7044 FAX Atkinson, NH 03811 AirQualityEtperts@AQENH.com
October 8, 2014
North Hampton Health Department
23 Service Center Road
North Hampton, MA 01060
Dear Sir:
Enclosed please find a copy of notification sent to the state for an Asbestos
Abatement Project.
The job will take place on October 17, 2014 to October 24, 2014.
Project: Sylvester Road Repair
Sylvester Road South End Culvert
Any questions concerning this matter should be directed to my attention.
Sincerely,
de„ !^.,a°`r-_
Christopher Thompson
President
4 12 .3CPM
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
`l
No. 569 F. 2
100208726
Asbestos Project#
✓ Project Revision
✓ Project Cancellation
,ctions 1.M
ns of this form CinfTOwn State Zlp COM Telephone
▪mmPleled^ NOQiaWMrow DPW N/A
to comply with
fP notification
anaM1s 1310
'A5 and
tenant of Labor atlldre Name,King Floor,Rain,etc.
eras(DLS) 2. Is the facility occupied? f'Yes Fm
seon
meets of 953
: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)? F! Yes r No
A. Asbestos Abatement Description
1.Facility Location:
SYLVESTER ROAD REPNR
SYLVESIER ROAD
Named Facity Street Address
MSRT AMMON Mw 01060
9135871510
Faiity Conran Person Nana Fadity Contact Fees/anTile
Wolksile Lxalion: SYLVESTER RDSOUTH END CULVERT
YEP Use Ong
Restored
MIDrip/A
or nonw' th eel 6.Asbestos Contractor:
4.Blamer Permit Project Approval,if applicable!
Approval ID*
5.Non-Traditional Asbestos Abatement Work Practice Approval,
if applicable: Approve lox
ach melts NR OtWJIY EXPERTS INC 23 HALL KAHM ROAD
sros Program Mare Mtlreas
Ma 12008]
on,MA 02112- ATINSC 1 NH Welt 603894646$
cay/Town State LP Cade Telephone
AG00-0167 Contract Type: F Written
DLS License*
7. BRU'CEWIpQWNS
9.
Name or Codrabrs on-site Supervlsorlforeman
Mama Of Pmpd Mbnaor
Name of Asbestos Analytical tab
W. 10/112019
AS000310
DLS CERiacabonft
N/A
015 CertificNxnit
WA
ULS C .thtabona
1624/201/
IT Verbal
Project Start Date(M I3DATYY) End Date 18TVDDIYYYY)
AM-`0M11 WA
Wog wars-Maguey Though Fry Work Hours Satz day&Sunthy
1.1 what type of project is this?
r Demolition F Renovation F Repair r Other-Please Specify:
Revised:11/1312013 Page 1 of 4
2C'4
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
57 r.
100208728
Asbestos Projeet#
r Project Revision
Project Canexilation
A.Asbestos Abatement Description: (cont.)
12.Abatement procedures(check all that apply):
F. Glove Bag r Encapsulation r Enclosure r Disposal Only r Cleanup r Full Containment
Ell, Other-Please Specify: REGULATED
13 lob is being conducted_ r Indoars F Outd nis
14.'Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:
150 0
Linear Feet(Lin.Ft) SOOere Feet(SO.R)
Boiler,Bleaching.Duct Trasuite Pipe 15G
Tani:Surface Coatings Lin.Ft S4 ft Les.Ft. Sq.Ft.
Pipe Insulation Transits Shingles
Lin FL SO.Ft Loll.FL
Spray-On Fireproofing Ttansite Panels
Lin.R Sy.FL Lit Ft. Sq.Ft
Doths,Woven Fabrics Other-Please Specify:
Lin.Ft Sq.Ft
Insulating Cement
Ljn.Ft SO.Ft LN.Ft S1.FL
19.Describe the decontamination systems)to be used
RFnrJtE/3 ewwr3ER MOON
16.Describe the containerizatioNdisposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2xg):
WET 2 PLY POLY
17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency:
Name of NhraDEP Of4oal Title at MasshEP OThcel
DateoiAubicrizaban RAWIPDnYYYI Werverl
Nang of ntS Official
tuleofOLS Officio!
Date of AUawnzeam RAMWPNVYYY) Waiver11
18.Do prevailing wage razes as per M.G L.c. 149,4 26.27 or 27A-F apply to this
project"
pit Yes r. No
Revised: 11/13/2013 Page 2 of 4
L24 -2 J1 M Ip .13a9 H 4
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100208726
Asbestos Project A
r Project Revision
r Pmjeci Cancellation -
B. Facility Description
1.Current or prior use of facility
CULVERT
2.Is the facility owner-occupied residential with 4 units or less?
3_CITY OF MDRh4MPNf1 BWJ,125 LOCI.MTFIRED-
Faaitty Owner Name
NJNTIWUPION
r Yes F NO
Address
MA 01060
4'35571570
City/Tow?'.
Slate zip Cole Teleplme
4 .WrES P 11D Th PC BOX91
Name)of Fxcdlty Owrcrs On-Site Manwser Address
SUNDERLAND MA 01375
4136657021
City/Town
State Zip Code Telgncae
5.WARNER OROS POOOX al
Nano of Gwieral Contractor Address
SUNDERLAND MA 01375 4136557021
Coy/Tows State Lp Code Telephone
Temporary WA
e of Aaheatps Contractor's Workefs Compensation Insure
nine waste WA 17112015
el is only
id at the piece Policy s Expiration Date(MMIDONYIM
news of e DLS
re)AASes guar
6.\Vhatis the size of this facility? a
that is
had by Square Feet Cot Floats
MP aaT d C. Asbestos Transportation & Disposal
tan ce with Solid
Re9Wetone L Transporter of asbestos-containing wale material from site of gencmtion:
NR ib 000
[' Directly to Landfill or E To Temporary Storage Locatio&Transfer Station
SERVICE TRANSPORTGROL4,IN0 PO BOX 2132
Name of Transporter Address
t3RA"IR PA 19007 0779999559
C iryrtolm State LP Cads Telephone
2,If a temporary storage location/transfer station is used_list name of trau.porter of asbe=stos containing
waste mater'el from temporary storage IocatioNtreasfcr station to final disposal site:
SERVICE TR/v.910AT GROUP,INC PC BOX 2132
Name of Transporter Addro65
9RISrOL PA 1900/ 6779399559
City/Town SEE Zip Code Telephone
Revised.11/132013 Page 3 of 4
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
569
100208726
Asbestos Project
r Project Revision
IT Project Cancellation
-erne-am must
is ram for oust C.Asbestos Treasporlation& Disposal: (dons) -
a5nn porusas 3.Name and address of temporary storage Ioeatienhransfer station fir the asbestos confairting avast
maleial.
SERVICE 1RrWFORT GROUP,NC. xa PRNLEGE SRRF£r
Temporay Storage Lccalia i Name
WOONSOCKET
Address
F1 02895
Ciry/Tmm
901768/824
Stole Zip Coto Telephone
4_Name and location of final disposal site(asbestos landfill):
MNERVAILNDF1f1 N/A
Dna MSposal Ste Name Final Gapasal Sae Owner Name
900 MNERVA ROAD
Adorns
WAYNESBURG 04 44888
3308883435
city[rown
D. Certification
celtity That I have personally
examined the foregoing and am
Moldier with the Information
mntainod in this document and
all attachments and that,based
on my inquiry of those
individuals!mmedialely
responsible for obtaining the
information,I believe that the
information Is Pue,accurate,and
complete.I am aware that there
are significant penalties for
submitting false information,
including possible lines and
imprisonment.The undersigned
hereby states that I have read the
Commonwealth of
Massachusetts regulations
governing asbestos abatement
(453 CMR 6.0D promulgated by
Me Department of Labor
Standards and 310 CMR 7.15
promulgated by the Department
of Environmer lel Protection),
and that I em aware that this
norm*application or nottcation
stn all not be deemed valid
unless payment of the
applicable tee is made."
Stale Zip Code Telephone
CHBSTOPNFRIHOWPON pR5NP1ERTIDMSDN
Nana
lfi✓ESiFNT
Autivxlzed Sgnature
102014
P1akWhlle 13g3(MMI00lyyril
6039846465 AIR QUALITY EXPERTS,INC
Telephone Repesenbng
23 HULL FARM ROAD ATN
Adaeaa City/Town
Ht 03811
Stile Zip Code
Revised:11/13/2013
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