109 Asbestos Notification Form 2012 DCommonwealth of Massachusetts
Asbestos Notification Form ANF-001
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VV
00154859
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?IAI Yes ❑No
b.Provide blanket decal number if applicable:
2. Facility Location:
EDWARD HATHAWAY RESIDENCE I
a.Name of Facility
Northampton AMA
a City/Town d State
INSTRUCTIONS 3. WorkSite Location:
1.All sections of this
form must be
completed in order
to comply with 4
DEP notification
requirements of 310
CMR715 5.
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 612
0
N
6.
!RESIDENCE
Blanket Decal Number
1109 SOUTH STREET
b.Street Address
01060 ! 14132141203
e.Zip Code
a Building Name/Building Location b.Building it
Is the facility occupied? 'Z'Yes ❑No
Asbestos Contractor.
ACCUTECH INSULATION 8 CONTRACTING Ill
a.Name
LUDLOW
C.City/Town
101056
d.Zip Code
f Telephone Number
c.Wmg d.Floor e.Room
1100 STATE STREET
b.Address
14135835500
IAC000005
DOS License Number
[EDWARD HATHAWAY
h.Faciuty Contact Person
[SAMUEL JUSINO
a.Name of On-Site Supervisor/Foreman
ATC ASSOCIATES,INC.
?' a.Name of Project Monitor
8 SCILAB
a.Name of Asbestos Analytical Lab
8/15/2012
a.Project Start Date(mnJddlyyyy)
18AM-5PM
e.Telephone Number
g.Contract Type: Written ❑Verbal
i.Contact Person's Title
c.Work hours Mon-Fn.
10 a Vvhat type of project is this?
° ❑Demolition 0 Renovation
❑ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
o ii Glove bag ❑ Encapsulation
o ❑ Enclosure ❑ Disposal only
❑Cleanup D.Other, specify:
❑ Full containment
Z
anfOOlap.doe•
1AS001283
b.Supervisor/Foreman DOS Certification Number
AA000005
b_Project Monitor DOS Certification Number
1AA000162
b.Asbestos Analytical Lab DOS Certification Number
1 /1512012
b.End Date(mn dWyyyy)
N/A
d.Work hours Sat-Sun.
b.Describe
b.Describe
12. Is the job being conducted: Ji Indoors? Lei Outdoors?
10/02
Asbestos Notification For•Page 1 of 3 U
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2
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100154859
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or
encapsulated:
0 140
'871:481 pipes or ducts(finea7t) b.Tot al other surt_aces(square fl)
c.Boiler,breathing,duct, _,tank 1 40 i r
d.Insulating cement
surface coatings Lin.ft. Sq.ft. Lin.t Sq.ft.
e.Corrugated or layered paper f.Trowel/Sprayer coatings
pipe insulation Lin.ft. Sq.ft. Lin.ft.
g.Spray-on fireproofing Lin.ft. 6q.ft. It Transite board,wall board Lin.fl.
Cloths,woven fabrics
k.Thermal,solid core pipe
insulation Lin.ft.
Lin R.
S9_fi. I.Other please specify' Lin.ft.
Sq.ft. tl.Specify
Sq.ft
i
Yq ft.
I
Sq.ft.
14. Describe the decontamination system(s)to be used:
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 VEHICLI
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
NIA
a.Name of DEP Official
N/A
b.Title
c.Date(mm/dd/yyyy)of Authorization
N/A
d.DEP Waiver#
!N/A
N/A
e.Nance of DOS Official f DOS Official Title
N/A
g.Date(mm/ddtyyyy)of Authorization h.DOS Waiver
17 Do prevailing wage rates as per M.G.L. c. 149, §26,27 or 27A—F apply to this project? ❑Yes Et] No
B. Facility Description
1 Current or prior use of facility
!RESIDENTIAL
2 Is the facility owner-occupied residential with 4 units or less' 1j7j Yes ❑ No
3 EDWARD HATHAWAY
a.Facility Owner Name
NORTHAMPTON 1 101060
C.City/rown d.zip Code
4. SAME._
a Name of Facility Owner's On-Site Manager
(SAME L
c.City/town d Zip Code
anf001 ap.doc•10/02
!109 SOUTH STREET
b.Address
1413-214.1203
e.Telephone Number ea code and extension)
,SAME
b-On-Site Manager Address
SAME
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3 U
Commonwealth of Massachusetts
LIAsbestos Notification Form ANF-001
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
tiffIi
0
0
aria
2
100154859
Decal Number
B. Facility Description (cont.)
5. a Name of General Contractor
b Address
c.City/Town d.Zip Code e.Telephone Numberfarea code and extension)
CHART'S 1 rWC005-31-9996 j 11/4/2012 .
f.Contractor's Worker's Comp.Insurer g.Policy Number h.Exp.Date(mm/dd/yyyy)
I
6. What is the size of this facility?
a.Square Feet b Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
IACCUTECH INSULATION 8 CONTRACTING,II 100 STATE ST. BLDG 119, PO BOX 376
a Name of Transporter b Address
'LUDLOW ;01056 j ;4135835500
�c.City/Town d Zip Code e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site
3.
[TRANSWASTE, INC
a.Name of Transporter
WALLINGFORD
c.City/Town
a.Refuse Transfer Station and Owner
3 BARKER DRIVE
b.Address
1 X106492 1 12032698300
a Zip Code e.Telephone Number
c City/Town
BFI IMPERIAL LANDFILL
d Zip Code
b.Address
e.Telephone Number
a.Final Disposal Site Location Name
FPO BOX 47-11 BOGGS ROAD
c.Final Disposal Site Address
IPA , I [15126
e.State
f Zip Code
b.Final Disposal Site Location Owners Name
!IMPERIAL
d.City/Town
g.Telephone Number
D. Certification
The undersigned hereby states, under the
Pe It fp rj ry,th th / h h dth
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.
[FAITH LEMAY
a.Name
ADMIN ASSIST
C. Position/Title
4135835500
e Telephone Number
1100 STATE ST. BLDG 119,
q.Address
;LUDLOW
h.City/Town
th LeMay
b.Authorized Signature
8/1/2012
tl Date(mm/ddhiWy)
IACCUTECH INSULATION!
f Representing
PO BOX 376
X01056
i Zip Code
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