245 Asbestos Notification Form 2011 LIAsbestos Notification Form ANF-001
Commonwealth of Massachusetts
tportant
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ay.
ISTRUCTIONS
100129894
Decal Number
All sections of this
,rm must be
3mpleted in order
,comply with
'EP notification
,quirements of 310
'.MR 7.15 5.
nd the Division
t Occupational
iafety(DOS)
o
afication
equirements of 453
MR 6.12
A. Asbestos Abatement Description
1. a. Is this facility fee exempt-city,town, district, municipal housing authority, owner-occupied
residence of four units or less9 GI Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
SAM TAYLOR
a.Name of Facility
'Northampton
c.City/Town
ll
L
Blanket Decal Number
11245 NORTH ST
1 MA
d.State
3. Worksite Location:
EASEMENT
a.Building Name/Building Location b.Building#
4. Is the facility occupied?
o
l °
N
a 0
0
MISIE0
0
LL
6
7
8
9
Asbestos Contractor:
C Yes No
b.Street Address
01060
13137209473
e.Zip Code f.Telephone Number
c.Wing
d.Floor
e.Room
ACE ASBESTOS REMOVAL&INSULATION
a.Name
NORTHFIELD j01360
c.City/Town d.Zip Code
1A0000006
f.DOS License Number
J
1101 CROSS RD
b.Address
14134980201
e.Telephone Number
g. Contract Type:
,u Written ❑Verbal
THOMAS SHEARER
h.Facility Contact Person
[THOMAS R.SHEARER
a.Name of On-Site Supervisor/Foreman
LNA
a.Name of Project Monitor
NA
SUPERVISOR
i.Contact Person's Title
a.Name of Asbestos Analytical Lab
7/21/2011
a.Project Start Date(mm/rid/yyyy)
7-5
AS070066
b.Supervisor/Foreman DOS Certification Number
11
1
c.Work hours Mon-Fri
10. a.What type of project is this?
❑Demolition ❑Renovation
❑Repair 0 Other, please specify:
11. a.Check abatement procedures:
❑Glove bag
rn Enclosure
❑Cleanup
❑Full containment
12. Is the job being conducted:
anf001 ap doc•10/02
[f Encapsulation
Z Disposal only
❑Other, specify:
b.Project Monitor DOS Certification Number
b.Asbestos Analytical Lab DOS Certification Number
7/22/2011 7
b.E nd Date(mot dd/yyyy)
LNA
d.Work hours Sat-Sun.
DISPOSAL ONLY
b.Describe
b.Describe
Indoors? k Outdoors?
Asbestos Notification Form•Page 1 of 3
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100129894
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
261
a.-TOtiriwpes or ducts(linear ft)
c.Boiler.breaching,duct,lank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
i.Cloths.woven fabrics
k.Thermal,solid core pipe
insulation
60 1
a ofr7S Vices(squarer
I
—�
Lin. 6q ft d.Insulating cement
L
1261 I IL I t.Trowel/Sprayer coatings
Lin.ft. Sq.fl.
Lin.fl. Sq.ft.
Lin.ft.
h.Transite board,wall board
1 i other,please specify:
ft
mI.Specify
Lin.ft. Su.ft.
14. Describe the decontamination system(s)to be used:
L 1 i
Lin.ft. _ Sq.ft.
r— _ J L
Lin.ft.____J fl.
Lin.ft. q.ft.
I 1Ir
Lin.fl. Sq.ft.
INA
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
IREWET ASBESTOS AND PACK IN DOUBLE, LABLED AND SEALED POLY BAGS
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
a.Naa PP cial
I �
Ib.Tie
c.Date(mm/dd/yyyy)of Authorization d.DEP Waiver I*
[e. Name of DOS Official
L —1 1
g.Date(mm/dd/yyyy)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 JI No
f.DOS O%ical rifle
B. Facility Description
1 Current or prior use of facility:
2 Is the facility owner-occupied residential with 4 units or less? Z Yes ❑No
DWELLING
SAM TAYLOR
a.Facility Owner Name
[NORTHAMPTON
c.City/Town
245 NORTH ST
b.Address
[01060
d.Zip Code
4. INA
a.Name of Facility Owner's On-Site Manager
WMa n.City/Town d.Zip Code
13137209473
e.Telephone Number(area code and extension)
b.On-Site Manager Address
e.Telephone Number(area code and extension)
anf00lap doc•10/02 Asbestos Notification Form•Page 2 of 3 U
1 Asbestos Notification Form ANF-001
Commonwealth of Massachusetts
Pt Transfer
aliens must
imply with the
clid Waste
ivision
agitations 310
MR 19.000
eaelailiNG
0
MEMO
0
100129894
Decal Number
B. Facility Description (cont.)
FACE ASBESTOS REMOVAL AND INSULATIO
5. a.Name of General Contractor
;NORTHFIELD 1 101360 H
c.City/Town d.Zip Code
1NA
f Contractor's Workers Comp. Insurer
6. What is the size of this facility?
r01 CROSS RD
b.Address
14134982092
e.Telephone Number(area code and extension)
I
Fq.Policy Number h.Exp.Date(mn dd/yyyy)
L2000 ; 2
a.Square Feet b.Number of floors
7
J
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
FACE ASBESTOS REMOVAL AND INSULATIO1
a.Name of Transporter
INORTHFIELD J 101360 1
c.City/Town d.Zip Code
1101 CROSS RD
b.Address
14134980201
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
I
TRANSWASTE INC.
a.Name of Transporter
WALLINGFORD ; (06492
c.City/Town d.Zip Code
J
3. TINA
a.Refuse Transfer Station and Owner
4. ;BFI IMPERIAL LANDFILL
a.Final Disposal Site Location Name
PO BOX 47.11 BOGGS ROAD
c.Final Disposal Site Address
`PA
e State
c.City/Town
J
( 1
d.Zip Code
3 BARKER DR
b.Address
12032698300
e.Telephone Number
15126
f.Zip Code
b.Address
e.Telephone Number
BROWNING FERRIS IND
b.Final Disposal Site Location Owners Name
(IMPERIAL
d.City/Town
7246950900
g.Telephone Number
D. Certification
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.
0
u
I anf001ap.doc•10102
THOMAS R SHEARER I
a.Name
;PRESIDENT
C.Position/Title
4134980201
e.Telephone Number
101 CROSS RD
g.Address
NORTHFIELD
h.City/Town
J
I
Thomas R Shearer
b.Authorized Signature
7/7/2011
d Date(mmrdd/WW)
ACE ASBESTOS REMOVI
f.Representing
X01360
i.Zip Code
Asbestos Notification Form•Page 3 of 3