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421 Asbestos Notification Form 2016 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100244248 Asbestos Project N c Project Revision t Project Cancellation Instructions 1.A6 sectors of this roan mist be completed In order b°e pty MAat Mme013,nottoalon regienerb of 310 CUR 715 and DenaMyst of tabor SWdertb(DLS) nofinton requirements of453 CUR 612 Mes4DEP Use tidy Data Renamed 2.Swot Gegwl Fans To: Cemmenwe•i h of 6.Asbestos Contractor: amachusetls AEfio 1ECNENVISONKENTAL P.O.Solt 4042 Boston,MA 02211 Nane A. Asbestos Abatement Description 1.Facility Location: VASE Kane of Fading I RRMPfai Crown MO ALS\PE]EZ 421 NMAIN ST Street Address IAA 01502 4135844040 Sete Zp Cade depots FACtnYENG ISEAE Fedlly Ca1al Pelson Name Worksim location: 2. Is the fruity occupied? b Yes a No Ffly Curled Person Ile BI LDNG 1 BASEMENT Biting Nene,Wing,Floor.Room,eic 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)? b Yes a No 4.Blanks Permit Project Approval,if applicable: Atpmva ID• 5.Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: Approval 11)* 163 RCE AVE Address IAA 01532 6783758534 Gltyff own AC000521 Sob Zip Cale Teleptte Contract Type: b Written e Verbal 01S Uses.• 7. rdEGORYW.tARDNG Name reCorpances OnSle StpeneorFaremen g. JAMES SSOAELL Name of Poled Morita 9. Are°ROLFW-RYCES NC Name of Asbestos Arsytal tab 10. an1e2a18 Palen Salt Dab IMMADIVY(Y) 8AM?Pal Work tours-meow Trfoph Fnday 11.What type of project is this? c Demolition b Renovation c Repair c Other-Please Specify: A5000278 DIS Caetcabon• AM073784 aS CeIClont AAD00005 OLS CerMntons 6119/2016 End Dale(MMONYYVY) GAM7Pi4 WMk Han-SetndaY 4 SoweY Revised:11113/2013 Z aBad Page 1 of 4 99EEE6E80S leyuaunxuy.u3 ?al oleV wdez:8 9lO? ZZ enf Commonwealth of Massachusetts As bestos Notification Form ANF-001 1 100244248 Asbestos Project M e Project Revision e Project Cancellation A.Asbestos Abatement Description: (cent) 12.Abatement procedures(check all that apply): e Glove Bag e EncapsuYtion c Enclosure b Disposal Only a Cleanup e Full Containment e Other-Please Specify 13.fob is being conduced: b Indoors e Outdoors 14.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed, or encapsulated: 2 Linear Feel(Lin Ft) Souse Feet(Sq.Fl.) Boiler,Breaching Duck TransNe Pipe Tank Surface Coatings tin Ft Sc.Ft. Lin.Ft Sq.Ft Pipe Insulation Transite Shingles Lh.Ft. SD.Ft. lin.Ft. S .Ft. Spray-On Fireproofing Tmnsite Panels Lin.FL Set Ft Lin.Fl. Sq.Ft Cloths.Woven Fabrics Other-Please Specify: Una Sq.F1. Insulating Cement GASKEY 2 Lin.Ft 9q.Fl. pin.Ft 15.Describe the decontamination system(s)to be used 2 CHAM3ER WASH BUCKET 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): 6 MILLDOLELE RAG 17.For Emergency Asbestos Operations,the MassDEP and DLS officals who evaluated the emergency: aline ofitaaDEP akin TS of Meeelle n Dale of MMa'vahon(Ma4DDIYYYY) VMirer s nNrre of DLS Official The of DLS OIdal Date ofAlrlormaon(MMDDIYYYY) evolved 16 BDolprerallfgMUagaffiSper181.G.L.[D.049,4226,27(007A—F apply to this project? b Yes e No Revised: /1/132013 [sage 2 of 4 E sEed S9EEE6EBO5 1ewou,vo.fAU3 Del °Jay 6Jd6ZIS 9102 ZZ unr Li c----- Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100244248 Asbestos Project N e Project Revision e Project Cancellation rdeaa:Temporary Noma orAabesbs conbadlp waste =tenet Is only allowed at the place o leos/non of a MS licensed Aabes Palley* catsbrore termer er t a• me a t 6.What is the size of this Facility? MaaetEP and Operated in compeers%wan Sofd Waite Regulations 310 CNR 19.000 B. Facility Description 1.Current or prior use of facility: HOSPITAL 2. Is the facility owner-occupied residential with 4 wilts or less? 3.VAMC 421 NMAN ST e Yes b No Faddy Corer Name Address NOR 144/F CM IAA 31801 4135844040 Citylrwn Sala 2p Cade Telephone 4.NA MA Name of Fadtty O sees OnStle Nkmger Address NA MA 00000 0005000000 City/Town Stale Zlp Cade Telephone 5 ao1E0 1a3RCE AVE Name of Cenral Cordactar NORTH3CROUGH Addren MA 01532 9783759534 Cityfrown Sap rap Cade Telephoto ACE Contractors Nbd®ts Connpereefon Mower 685209 5/7/2017 Nos:contrast most Eiptaaon oats(M1&CONYW) 3900 3 Spare Feet C.Asbestos Transportation& Disposal *of Floors 1.Transporter of asbestos-containing waste material from site of generation: a Directly te Landfill or b To Temporary Storage LOCation?mm&r Station AFRO IECEN1ltdMENTAL 163 RICE AVE Name of Transporter PCR714300000ll Address 044 01532 97E3759514 171WIaan State Zap COda Trepnors 2.If a temporary storage location/transfer station is used, list name ofnareporter of asbestos containing waste material from temporarystorage bcatiodbamfer station to fossl disposal site: Im 173PICKERNG ST Nate of Transporter PORT Na Address Cr 08490 81303421022 CIyrnsen Sale 2y Cade Telephone bon Paawmmr OLS Revised. 11/132013 (Page 3 of 4 ir abed 59E££6E8o5 leq0eusnenu3 nay ouey Wd638 91.0Z ZZ am ci iCommonwealth of MaacMrsem ssAsbestos Notification Form ANF-001 100244248 As testae Project it y Project Revision e Project Cancellation III/1111W uem pi/WOO C.Asbestos Transportation d Disposal:(coat) 3.Name and address of temporary storage bcation/Uansfer station for the asbestos containing waste mated: NA NA Temporary Morage Lorabon fame NA Address Wi 00000 0000000900 miarrown stab hp Code Telephone 4.Naar and location of final disposal site(asbestos landfill): MN4NAavIBSRME u*aA ENIEiPREE Flrd Dsposal Sda Maros Fllel O{Nneet Se Owner Name 9000 MPERVA RD Adaeaa WAY!ES9LFG CR 41885 Cityrrown D. Certification "I rectify that I have persoresy examined the foregoing and am familiar with the information contained in this documem and all attachment and that,based on my irlq:iry of those individuals immediately responsible for obtaining the information, I believe that the information b true,accurate,and complete. I am aware that there are signifIcam penaitias for submitting false information, including possible tines and imprisonment.The undersigned hereby states that I have read the Commonwealth of Massachusetts fegwations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promugated by the Department of Environmental Protection), and that l am aware that this permit application or notification shall not be deemed valid unless payment of the applicable tie la made." 330858:435 st S isi Corte Teepinne GREG(RYWYVPIG GEGORY 1AMNG Nose AS dead Signature OMER GI/2016 PomionTde Date(MMDD/YYYY) 0783759534 AEROT9 Tebptnre Rebmann; 153 RICE AVE NORM:CROUCH Address City/fown MA 01532 Stab Zp Code Revised•11/13/2013 g abed Page 4 of 4 99EE£6E809 IeluawssWNo3 Jel 419V Wd6Z:8 9lOZ ZZ uhf 1 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 Project Revision Notification I10021.4248R1 Asbestos Project Id b Project Revision e Project Cancelktion (MDeetbtn 1.At secaomoferis form mist be completed in ardor to campy with Mayer tattcsson requremems o1310 CAR 7.15 and DevoWVta(labor A. Asbestos Abatement Description 1.Facility Location: VAMC Nana of Facility MCIU WRPfw Ckyrrown MIDONaAPEREZ 421 NMAN ST Street Address MA 01802 4135844040 Stab ZM Cade Tehgane FACLT'EtGDII� Fad4lyCartad Person Name Wotksite location: Standade(Over) 2. nleoket Permit Ptojea Approval, if applicable: nolikren cMR&12 ms of 453 CIAR812 3.Non-Traditional Asbestos Abatement Work Practice Appro if applicable MAeaDEP the Only Dale Received Parity Contact Person lea Btlt1MGilia¢MENT Biking Name.W(g,Floor.Room,etc. 82x2016 PTv$ed start ore IMM,00mv) WA 7PM 2.S10mmMDmgrel Mork Hey Mdltday T!Iolgh Felony Fpm To: cotmnun salt of B.Other Project Revisions: Massachusetts P.O.Box1002 Boston,MA 02211 row Temporary serape MAdaeks containing waste material is only Sowed at 111 plsoe m busiesscta BLS licensed AebMW mrtrector era transfer elation that is permitted ty MaseDEP and operated it compliance with Sod Wan Regulations 310 PM 19000 g AMM STARTDATE 828/2016 Approval ID ft vat, Approval IDs Ed Dote dineWrelnard SAM 7PM Work tours-Sruday a Sunday Revised:/1/13/213i3 9 abed Page 1 oft 59EEE6E809 le1uaustory.u3 Dal 0.0V 14d638 9t0Z ZZ unr Commonwealth of Massachusetts Asbestos Notification Form ANF-001 Project Revision Notification 103214248R1 Asbestos Project U b Project Revision Project Cance nation 11W6 ww0.111 114YL egn eat form for pls C. Certification notification purposes "I certify that I have peeonally examined the foregoing and an familiar with the information contained in thisdocument and all attachments and that,based on my inquiry of those indiaduals immediately responsible for obtaining the information,I believe that the information Is true,accurate,and complete. I am aware that these are significant penalties for submimng face information, incita!rg possible fines end imprisonment.The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 pramulgeted by the Department of Labor Startlarda and 310 CMR 7.15 promulgated by the Department of Environment l 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," GFa(ORYPAM NG GREGORY HARDNG Nara Atithrened Signature OMER 01182018 PcSoV1 tie Date(14a4DDM'YY) 97a75a34 PERD IEC Teleytice Rig 163 ROE AVE NCRTHBORCOGel Address Darrow MA 01532 Sale Definite Revised: 11/13/2113 L aged Page 2 of 2 59£££6£805 letuewi0403 Dal ° V NdoE:8 9WZ ZZ unf FAX Aec PO BOX 929 NORTHBORO,MA 01532 gregda aerotecasbestesremovatcom PHONE: 978-375-9534 ATT : BOH Fax : 413-587-1221 FROM: Greg Harding DATE: 6/22/2016 PAGES: n FAX: 508-393-3365 59EE£6E805 Iewewuzamj Del aaV Wd638 9 FOZ ZZ ear