137 Unit M111 Asbestos Notification Form 2013 portanc
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uirements of 310 5.
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
■
I100184537Q)(oyye�
Decal Number . ,
01111NkV59101U3
A. Asbestos Abatement Description
t a. Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied
residence of four units or less? ri Yes ❑ No
b.Provide blanket decal number if applicable:
2. Facility Location:
NHA-FORSANDER APARTMENTS, BLDG N
a.Name of Facility
Northampton
c.City/Town
3. Worksite Location:
NHA-FORSANDER APTS.
a.Building Name/Building Location
4. Is the facility occupied?
0
0
o
0
u
2
Asbestos Contractor:
MA
0.State
N
b.Building#
Yes ❑No
'ABIDE INC
a.Name
EAST LONGMEADOW
c.City/Town
01028
d Zip Code
AC000254
f.DOS License Number
BILL CELATKA/B-G MECHANICAL SERVICE,
h.Faality Contact Person
CHRISTOPHER J.COOPEE
6. a.Name of On-Site Supervisor/Foreman
TBA
7' a Name of Project Mon for
TBA
8. a.Name of Asbestos Analytical Lab
9 19/20/2013
a.Project Start Date(mm/dd/yyyy)
7AM-5PM
c.Work hours Mon-Fri.
10. a. What type of project s this?
P2
❑ Demolition Renovation
❑ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
Glove bag
❑ Enclosure
❑ Cleanup
Full containment
a 12. Is the job being conducted:
anf00lapdoc•10/02
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
Blanket Decal Number
1116-123 HIGH STREET
b.Street Address
01062
e.Zip Code
c.Wing
f.Telephone Number
d Floor
MECHANICA
e Roam
483 SHAKER ROAD
b.Address
4135250644
e.Telephone Number
g. Contract Type: ❑Written
17
Verbal
'GENERAL CONTRACTOR
Contact Person's Title
AS070247
b Supervisor/Foreman DOS Certification Number
N/A
b.Project Monitor DOS Certification Number
N/A
b.Asbestos Analytical Lab DOS Certification Number
9/20/2013
b.End Date(mm/dd/yyyy)
d.Work hours Sat-Sun.
b.Describe
b.Describe
Indoors? ❑Outdoors?
Asbestos Notification Form•Page 1 of 3
N
o 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project?
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100184537
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed,enclosed,or
encapsulated:
6
a.Total pipes or ducts(linear ft)
c.Boiler.breathing,dud,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
i.Cloths.woven fabrics
k.Thermal,solid core pipe
insulation
1166
b. I ofal other surfaces(square ft)
Lin.ft.
Lin.ft.
Lin.ft.
Lin.11
Lin.ft.
16
Sq.ft.
Sq.ft.
5 ft.
d Insulating cement
f.Trowel/Sprayer coatings
h.Transite board,wall board
j.Other,please seedy:
Lin
ft.
Lin
ft.
Lin.ft.
6
Lin.ft.
100
Sq.ft.
Sq.ft.
160
Sq.ft.
'CAULK
Sq.if I.Specify
14. Describe the decontamination system(s)to be used
REMOTE AND/OR CONTIGUOUS THREE STAGE DECONTAMINATION UNIT W/SHOWER
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
ACM ADEQUATELY WETTED, DOUBLE BAGGED,SEALED AND LABELED
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
'N/A 1
a.Name of DEP Official
c.Date(mm/dd/yyyy)of Authorization
N/A
e.Name of DOS Official
b.Title
N/A
d.DEP Waiver#
1f.DOS Official Title
NIA
g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver it
Yes❑ No
o B. Facility Description
1 Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or less?
HOUSING
3• a.Facility Owner Name
NORTHAMPTON HOUSING AUTHORITY
o NORTHAMPTON
o c.City/Town d.Zip Code
4 BILL CELATKA/B-G MECHANICAL SERVICE,
a.Name of Facility Owners On-Site Manager
01060
LL
2
c
anf001ap doc•10/02
CHICOPEE
c.City/Town
01020
d.Zip Code
❑Yes
No
49 OLD SOUTH STREET
b Address
1413-5844030
e.Telephone Number(area code and extension)
12 SECOND AVENUE
b.On-Site Manager Address
413-888-1500
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3
le:Transfer
lions must
nply with the
id waste
ision
gulations 310
IR 19000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100184537
Decal Number
B. Facility Description (cont.)
5.
BILL CELATKAIB-G MECHANICAL SERVICE,
a.Name of General Contractor
CHICOPEE
c.City/Town
01020
d.Zip Code
f.Contractor's Worker's Gomp.Insurer
6. What is the size of this facility?
12 SECOND AVENUE
b.Address
413-888-1500
e.Telephone Number(area code and extension)
q.Palley Number
2,000
a.Square Feet
h.Exp.Date(mm/dd/yyyy)
2
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
'ABIDE, INC.
a.Name of Transpoder
'EAST LONGMEADOW
c City/Town
01028
d.Zip Code
2. Transporter of asbestos-containing waste material
'ABIDE, INC.
a.Name of Transporter
'EAST LONGMEADOW
c City/Town
3. ITRANWASTE, INC.
a.Refuse Transfer Station and Owner
01028
d.Zip Code
WALLINGFORD, CT
c.City/Town
4. 'MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
19000 MINERVA ROAD
c.Final Disposal Site Address
OH
e.State
06492
d.Zip Code
44688
f.Zip Code
P.O. BOX 886
b.Address
4135250644
e.Telephone Number
from removalltemporary site to final disposal site:
P.O. BOX 886
b.Address
14135250644
e.Telephone Number
13 BARKER DRIVE
b.Address
12032698300
e.Telephone Number
b.Final Disposal Site Location Owners Name
[WAYNESBURG
d.City/Town
g.Telephone Number
D. Certification
°
2
anf001ap.doc•10/02
The undersigned hereby states, under the
penalties of perjury,that he/she has read the
Commonwealth of Massachusetts regulations
for the Removal, Containment or
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15, and that the information
contained in this notification is true and correct
to the best of his/her knowledge and belief.
MARIA TILL(
a.Name
PRESIDENT
c.Position/Title
4135250644
e.Telephone Number
'P.O. BOX 886
q.Address
'EAST LONGMEADOW
h.City/Town
'Maria Tilli
b.Authorized Signature
8/30/2013
d.Date(mm/dd/vyyv)
'ABIDE, INC.
f.Representing
01028
i.Zip Code
Asbestos Notification Form•Page 3 of 3 1