10 Asbestos Notification Form 2014 Important:
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INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100199763
rDecal 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? S Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
ANDREW SMITH RESIDENCE
a Name of Eacltti._
NORTHAMPTON MA
c.City/Town d State
3. Worksite Location:
1.All sections of this
form must be
completed in order
to comply with 4
DEP notification
requirements of 310
CMR7 15 5
and the Olssion
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 612
- N
0
0
-2
• anf001ap.doc•
RESIDENCE
a.Bolding Name/Building Location b Building#
Is the facility occupied? f✓',Yes i` No
Asbestos Contractor:
ACCUTECH INSULATION 8 CONTRACTING II
a.Name
01056
(LUDLOW
c OifRown d.Zfb Code
AC000005 -- - -- -
i.DOS License Number
ANDREW SMITH _
h.Faality Contact Person
WILLIAM A GIZA-BILODEAU
6 aT Name of On Ste Supervisor/Foreman
7 `N/A
a Name of Protect Monitor
8. ;N/A
a.Name of Asbestos Anasical Lab
9 '5/23/2014
Fa.Project Start Date lmmldElyyyy)
110AM-3PM
c.Work hours Mon-Fri.
10 a What type of project is this?
!fl Demolition 17 Renovation
Repair `l Other, please specify:
11. a. Check abatement procedures:
L Glove bag
[I Enclosure
l_j Cleanup
❑ Full containment
❑ Encapsulation
• Disposal only
'=( Other, specify:
Blanket Decal Number
'..10 MRYTLE STREET
b-Street Address
X01060 4132222536
e.Zip Code f Telephone Number
C.W ng
- ■ATTIC
d.Floor
100 STATE STREET
b.Address
4135835500
e.Telephone Number
e.Room
g. Contract Type: RI Written ❑Verbal
(HOME OWNER
i.Contact Person s Title
AS070522
b.Supervisor/Foreman DOS Certification Number
I WA
b.Project Monitor DOS Certification Number
IN/A
b.Asbestos Analytical Lab DOS Certification Number
15/23/2014
b.End Date(mmldd/yyyy)
II NIA
d.Work hours Sat-Sun.
b.Describe
b Describe
12. Is the job being conducted: J' Indoors? L Outdoors?
10/02 Asbestos Notification Form•Page 1 of 3
0
0
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
00199763
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 10
a Tatal pipes or duds(linear ft) bTotal otFer surfaces(square
c.Boiler,breathing,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
Lin.fl. 5r, fl.
d.Insulating cement
ft. 5r,.fl. f Trowel/Sprayer coatings
Lin.ft. So.ft.
b.Transite board,wall board
Lin R Sq.ft. j.Other,please specify:
1 r -
1TRANSITESIONG
Lin.ft. j Sq.ft. I.Specify�—- -
14. Describe the decontamination system(s)to be used:
Lin.ft. Sq_ft
Lin.ft. 1___ 59_R.
Lin.R.
Ho
Lin.ft Sq.fl.
DISPOSAL ONLY. DEMARCATE WORK AREA W/BARRIER TAPE. POST SIGNS.
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 VEHIC J
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
BOB SHULTZ
a.Name of DEP Official
! jN/A
b.Title
5/23/2014 W-184-14
c.Date(mm/dd/yyyy)of Authorization d.DEP Waiver#
rWWW.MASS.GOV/DOS 1 I,
e.Name of DOS Official f.DOS Official Title
I`/23I2014 9682-2014
y
g.Date(mm/dd/ yyy)of Authorization l
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 r! No
B. Facility Description
1 Current or prior use of facility:
'RESIDENTIAL
2. Is the facility owner-occupied residential with 4 units or less? _ZJ Yes J No
3
4
2
;ANDREW SMITH 10 MYRTLE STREET
a Facility Owner Name b.Address
NORTHAMPTON ■ 01060 413-222-2536
c.City/Town dZp Code Telephone Number(area code and extension)_
a Name of Facility Owners On-Site Manager b.On-Site Manager Address
I
SAME a ( _ '...SAME
a City/Town d.Zip Code e.Telephone Number(area code and extension)
anfarl ap.doc•10/02 Asbestos Notification Form•Page 2 of 3
Note Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19 000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100199763
Decal Number
B. Facility Description (cont.)
N/A
a.Name of General Contractor
':.N/A .l 1
c.City/Town d Z p Code
GRANITE STATE/RSG/RT
f.Contractors Workers Comp Insurer
6. What is the size of this facility?
N/A
b Address
(N/A
1
e Telephone Number(area code and extension)
WC005319996 111/4/2014
g Policy Number h Exp_Datejmm/dd/yyyyf,
11250...__ 3
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):
2
3
4
LACCUTECH INSULATION 8 CONTRACTING,I
Name of Transporter
'__.
''.LUDLOW .01056
c.City/Town d.Zip Code
Transporter of asbestos-containing waste material
TRANSWASTE, INC
a.Narne of Transporter
WALLINGFORD 06492
c Cy/Town d Zip Code._
N/A
_.. _ ..,
a.Refuse Transfer Station and Owner
N/A
aCty/TOwn d Zip Code
MINERVA ENTERPRISES INC I
a Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
OH ..__. 44688 -.._
e.State - _ -�- t Zip Code
1180 STATE ST. BLDG 119, PO BOX 376
b.Address
4135835500
e.Telephone Number
from removal/temporary site to final disposal site:
13 BARKER DRIVE
b Address
(2032698300
e.Telephone Number
iN/A
b Address
Telephone Number
'..MINERVA
b.Final Disposal Site Location Owners Name
!WAYNESBURG
d City/Town
)3308663435 _
g.Telephone Number
° D. Certification
0
z
The undersigned hereby states, under the
p Iti f p jury,that he/she has read the
C Ith f M h tt g I t
for the Removal, Containment or
Encapsulation of Asbestos,453 CMR 600 and
310 CMR 7.15, and that the information
t d th t t - t d ct
t th b t fh' /h k Idg dblf
anfOOl ap.doc•10/02
FAITH LEMAY
a.Name
ADMIN ASSIST
c.Position/Title
4135835500
e.Telephone Number
100 STATE ST. BLDG
Address
.LUDLOW
h.City/Town
vjF ITA '
Authorized H LEMSigYnature
'5/23/2014
d Date(mm/ddiyyyy)
__ ACCUTECH INSULATION
f.Representing
119, PO BOX 376
01056
T.Zip Code
Asbestos Notification Form•Page 3 of 3