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1TRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100124814
Decal Number
•
A. Asbestos Abatement Description
1. a. Is this facility fee exempt-city,town, district, municipal housing authority, owner-occupied
residence of four units or less?❑Yes 17 No
b. Provide blanket decal number if applicable:
2. Facility Location:
D.A.SULLIVAN &SONS
a.Name of Facility
Northampton
c.City/Town
3. Worksite Location:
D.A.SULLIVAN 8 SONS
a. Building Name/Building Location
MI sections of this
must be
npleted in order
:empty with 4
P notification
uirements of 310
IR7.15 5
1 the Division
)ccupational
ety(DOS)
ification
uirenlents of 453
R 6.12
0
6.
7.
8.
9.
Is the facility occupied? F2;Yes
Asbestos Contractor:
[MA
d.Stale
b.Building p
❑No
ACCUTECH INSULATION 8 CONTRACTING I 1
a.Name
LUDLOW_-------_._ x01056
C.City/Town
AC000005
DOS License Number
MARK SULLIVAN
`a.Zip code
rili
Blanket Decal Number
108 MAIN STREET
b.Street Address
01060
e.Zip Code
4135303745
f Telephone Number
[BASEMENT
c.Wing d. Floor
e.Room
100 STATE STREET
b.Addres
4135835500
e.Telephone Number
g. Contract Type:
Written ❑Verbal
h.Facility Contact Person
[SAMUEL JUSINO
a.Name of On-Site Supervisor/Foreman
IATC ASSOCIATES, INC.
a.Name of Project Monitor
SCILAB
1
a.Name of Asbestos Analytical Lab
5/9/2011
a.Project Start Date mMdd/yyyyj_
7AM-4PM
c.Work hours Mon-Fri.
O 10. a. What type of project is this?
❑ Demolition ❑ Renovation
• ❑ Repair ❑Other, please specify:
11. a. Check abatement procedures:
o ❑ Glove bag El Encapsulation
o Enclosure ❑ Disposal only
❑Cleanup ri Other, specify:
Full containment
Z
Contact Person's Title
AS001283
b.Su r/Foreman DOS Certification Number
AA000005
b.Project Monitor DOS Certification Number
AA000162
b.Asbestos Analytical Lab DOS Certification Number
5/10/2011
b nd Date(mm/ddl yyyy)
[N/A
d.Work hours Sal-Sun.
b.Describe
b.Describe
12. Is the job being conducted: [✓1 Indoors? I_I Outdoors?
anf001 ap doc•10/02
Asbestos Notification Form•Page 1 of 3 S
Commonwealth of Massachusetts
S. Asbestos Notification Form ANF-001
•
100124814
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or
encapsulated:
!0 1500
a.Total pipes or ducts(linear ft) 6 Total other surfaces(square X)
c.Boiler,breaching,duct,tank ■ d Insulating cement
surface coatings Lin.ft Sq.X. 9 semen
e.Corrugated or layered paper l l
pipe insulation Lin.X. Sq ft f.Trowel/Sprayer coatings
t
Lt
Lin.X. Sq.X.
i
Lin.X.
k.Thermal,solid core pipe L I 1
insulation Lin.ft. Sq.X.
g.Spray-on fireproofing
•Cloths,woven fabrics
14. Describe the decontamination system(s)to be used:
h.Transite board,wall board
j.Other,please specify:
VAT& MASTIC
I.Specify
Lin.X. Sq.ft.
Lin.ft. Sq.ft.
Lin.ft. q. .
1500
Lin.ft. So.ft.
SEAL CRITICALS W/6 MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNIT& INSTALL AIR
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
[ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY& DELIVERED IN A SEALED VEHICL
16, For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
N/A
a.Name of DEP Official
c.Date(mm/dd/yyyy)of Authorization
IN/A
e.Name of DOS Official
N/A
b.Title
N/A
d.DEP Waiver a
N/A
DOSd76ialTitle
N/A
g.Date(mmlddlyyyy)of Authorization
h.DOS Waiver tl
17. Do prevailing wage rates as per M.G.L.c. 149, §26, 27 or 27A—F apply to this project? ❑Yes SI No
° B. Facility Description
N
1 Cu r nt or prior use of facility:
RETAIL SPACE
2. Is the facility owner-occupied residential with 4 units or less?
D. A.SULLIVAN &SONS
3- a.Facility Owner Name
° NORTHAMPTON i 1,01060 1 1413-584-0310
°
G.City/Town d Zip Code
❑Yes
No
82 NORTH STREET
b.Address
z
4.
SAME
a.Name of Facility Owner's On-Site Manager
anfool ap.doc•10/02
c.City/Town
e.Telephone Number(area code and extension)
!SAME
b On-Site Maria•er Address
d Zip Code e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3•
le:Transfer
Dons must
nply with the
lid Waste
'Dion
gulations 310
IR 19 000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100124814
Decal Number
B. Facility Description (cont.)
5. L.-.-----
a.Name of General Contractor
i __._ __ . -J
c.City/Town d.Zip Code
SIG 1WC5318622
L Contractor's Worker's Comp.Insurer
b.Address
e.Telephone Number(area code and extension)
6. What is the size of this facility?
le Policy Number
a.Square Feet
11/4/2011
h.Exp.Date lmm/dd/yyyy)
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
ACCUTECH INSULATION&CONTRACTING, II
a.Name of Transporter
LUDLOW 01056
c.City/Town d.Zip Code
2. Transporter of asbestos-containing waste material
BRED TECHNOLOGIES J
a.Name of Transporter
[BLOOMFIELD 106002
-.__._.n_.. Zi
e.City/Town d.Zip Code
3.
a.Refuse Transfer Station and Owner
c City/Town d,Zip_Code
4. CINERVA ENTERPRISES INC
a.Final Dis osal Site Location Name
9000 MINERVA ROAD
Final Disposal Site Address
[OH J 44686
e.State f.Zip Code
100 STATE ST. BLDG 119, PO BOX 376
b.Address
4135835500
e.Telephone Number
from removal/temporary site to final disposal site:
10 NORTHWOOD DRIVE
b Address
18602182428
e.Telephone Number
b Addre
Q Telephone Number
b.Final Disposal Site Location Owner's Name
LWAYNESBURG
d.City/Town
L
g.Telephone Number
o D. Certification
The undersigned hereby states,under the
pe allies of perjury,that he/she has read the
o Commonwealth of Massachusetts regulations
f th Rem v I Containment or
• Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15, and that the information
t ' d th th' T ' t d 1
o to the best of his/her knowledge and belief.
0
z
anf0o1ap doc•10/02
FAITH LEMAY
a.Name
ADMIN ASSIST
c.Position/Title
14135835500
J
e.Telephone Number f.Representing
1100 STATE ST. BLDG 119, PO BOX 376
g Address
I LUDLOW l 101056
City/Town 1.Zip Code
oigrexi
F. th LeM1ey
..Authorized Signature
4/22/2011
d.Date(mm/dd/yyyy)
ACCUTECH INSULATION
Asbestos Notification Form•Page 3 of 3 III