77 Asbestos Notification Form 2010 1 Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
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TRUCTIONS
•
100109542
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? GI Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
BUCKLEY RESIDENCE
a.Name of Facility
Northampton
c.City/Town
3. Worksite Location:
II sections of
must be
1pleted In order
amply with 4
t notification
iirements of 310
3]15 5
the Division
Iccupational
Ay(DOS)
ration
ments of 453
3 6.12
IMA
d.State
Blanket Decal Number
77 HENSHAW AVENUE
b.Street Address
101060
e Zip Cade
BUCKLEY RESIDENCE
a.Building Name/Building Location b Building 11
Is the facility occupied? El Yes ❑No
Asbestos Contractor:
ACCUTECH INSULATION 8 CONTRACTING I
a.Name
LUDLOW
c.City/Town
AC000005
Ing
4135374088
f Telephone Number
BASEMEN)
d Floor
e Roam
1
100 STATE STREET
b.Address
01056 J 4135835500
f.DOS License Number
d Zip Code e Telephone Number
J g.Contract Type: ❑Written ❑Verbal
KERRY BUCKLEY
h.Facility Contact Person
6 (ANTHONY ROY,JR
a.Name of On-Site Supervisor/Foreman
7.
ATC ASSOCIATES
a.Name of Project Monitor
SCILAB
8. a Name of Asbestos Analytical Lab
1
18/1012 010
9' a.Project Start Date(mm/ddlyyyy)
[OWNER
i.Contact Person's Title
AS001257
b.Supervisor/Foreman DOS Certification Number
AA000005
b.Project Monitor DOS Certification Number
[AA000162
b.Asbestos Analytical Lab DOS Certification Number
18/10/2010
o 8AM-430PM
c.Work hours Mon-Fri.
10. a.What type of project is this?
❑ Demolition 0 Renovation
❑ Repair ❑Other, please specify:
11. a. Check abatement procedures:
❑ Glove bag
❑ Enclosure
❑ Cleanup
Full containment
0
12. Is the job being conducted:
anfootapdoc•10/02
Encapsulation
Disposal only
Other, specify:
ndoors?
b-E nd Date lmml tltll yyyy)
N/A
d.Work hours Sat-Sun.
b Describe
b Describe
11 Outdoors?
Asbestos Notification Form•Page 1 of 3
SEAL CRITICALS W/6 MIL POLY;ATTACH 3 STAGE DECON; INSTALL AIR FILTRATION EQUIPj
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100109542
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
40
a.Total pipes or ducts(linear ft)
c.Boiler,breaching,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
160
b.Total other surfaces(square n)
60
Sq ft.
Lin.n.
Lin.ft.
Lin.n.
Lin n
40
Lin.ft.
Sq.ft.
d. Insulating cement
f.Trowel/Sprayer coatings
h.Transite board.wall board
S j.Other,please specify'.
1.Specify
14. Describe the decontamination system(s)to be used
Lin.h.
Lin.ft.
Lin.9.
Lin
5q.ft.
Sq.ft
Sq f.
s
9
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 AND DELIVERED IN SEALED VEHIC4
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
NIA
a.Name of DEP Official
c.Date(mm/dd/yyyy)of Authorization
N/A
e.Name of DOS Official
g.Date(mm/dd/yyyy)of Authorization
b.rue
d DEP Waiver if
t.p05 Official Title
h.DOS Waiver#
17 Do prevailing wage rates as per M.G.L.c. 149, §26, 27 or 27A—F apply to this project? P1 Yes 51 No
° B. Facility Description
°
1 Current or prior use of facility
2 Is the facility owner-occupied residential with 4 units or less? [YYes ❑ No
RESIDENTIAL
3 'KERRY BUCKLEY
a.Facility Owner Name
NORTHAMPTON
0 c.City/Town
Z
4.
01060
d.Zip Cade
SAME AS ABOVE
a.Name of Facility Owner
)nf001ap.doc•10/02
c.City/Tawn
On-Site Manager
r.
d.Zip Cade
77 HENSHAW AVENUE
b Address
1413-537-4088
e.Telephone Number(area code and extension)
b On-Site Manager Address
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3
:11 Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
e'Transfer
lions must
rply with the
id Waste
son
ulations 310
R 19000
100109542
Decal Number
1
B. Facility Description (cont.)
5.
N/A
a.Name of General Contractor
c.City/Town
AIG
f.Contractor's Worker's Comp.Insurer
d.Zip Code
6. What is the size of this facility?
b.Address
e.Telephone Number area code and extension)
WC5312904
Policy Number
a.Square Feel
11/4/2010
h Exp.Date(mm/dd/yyyy)
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
ACCUTECH INSULATION &CONTRACTING, I
a.Name of Transporter
(LUDLOW
0.City/Town
01056
d Zip Code
100 STATE STREET, PO BOX 376
b.Address
4135835500
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
4.
RED TECHNOLOGIES
a.Name of Transporter
BLOOMFIELD
c.City/Town
06002
d.Zip Code
a.Refuse Transfer Station and Owner
c.City/Town
d Zip Code
MINERVA ENTERPRISES INC
a Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
OH
e.State
44688
f.Zip Code
10 NORTHWOOD DRIVE
b.Address
8602182428
e Telephone Number
L
b.Address
e Telephone Number
b.Final Disposal Site Location
WAYNESBURG
d.City/Town
ner's Name
g Telephone Number
• D. Certification
The undersigned hereby states,under the
o p If fp j ry,th t h / h h d th
0
0
LL
z
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
t d' th' tf t ' t d [
to the best of his/her knowledge and belief
nf001ap.doc 10/02
GLORIA JENKINS
a.Name
PRESIDENT
c.Position/Title
4135835500
e.Telephone Numb
J
b Authorized Sign
7/13/2010
d.Date(mm/dd/yyyr)
ACCUTECH INSULATION
L Representing
100 STATE STREET,
PO BOX 376
Address
LUDLOW
h.City/Town
01056
Zip Code
Asbestos Notification Form•Page 3 of 3