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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100184533 oars&
Decal Number
p(icr :5909M
A. Asbestos Abatement Description
1.
a. Is this facility fee exempt-citytown, district, municipal housing authority, owner-occupied
residence of four units or less? Al Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
3
All sections 1 dis
nn must be
mpleted in rder
comply with 4.
EP notificati n
puirements f 310
MR715 5.
id the Diesi n
Occupation I
defy(DOS)
tification
puirements 1453
Ali 6.12
6.
NHA-FORSANDER APARTMENTS, BUILDIN
a. Name of Facility
Northampton
a City/Town
Worksite Location:
NHA-FORSANDER APTS.
a.Building Name/Building Location
Is the facility occupied?
Asbestos Contractor:
MA
d State
J
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.Facility Contact Person
CHRISTOPHER J.COOPEE
a.Name of On-Site Supervisor/Foreman
ITBA
T a.Name of Project Monitor
8.
9
0
0
0
LL
Z
TBA
a.Name of Asbestos Analytical Lab
19/16/2013
a.Project Start Date(mm/ddyyyy)
AM-5PM
c.Work hours Mon-Fn.
10 a What type of project is this?
❑ Demolition
❑ Repair
17
Renovation
Blanket Decal Number
84-91 HIGH STREET
b Street Address
01062
e.Zip Code
c.Wing
f Telephone Number
d.Floor
MECHANICA
e Room
483 SHAKER ROAD
b.Address
14135250644
e.Telephone Number
g. Contract Type: ❑Written
12
Verbal
GENERAL CONTRACTOR
1.Contact Person's Title
AS070247
b.Supervisor/Foreman DOS Certification Number
IN/A
b.Project Monitor DOS Certification Number
IN/A
b.Asbestos Analytical Lab DOS Certification Number
9/16/2013
b.End Date(mm/dd/yyyy)
d Work hours Sat-Sun.
❑Other, please specify: b.Describe
11. a. Check abatement procedures:
1
Glove bag
❑ Enclosure
❑Cleanup
Full containment
Q
❑ Encapsulation
❑ Disposal only
❑Other, specify:
b.Describe
12. Is the job being conducted: IN Indoors? ❑Outdoors?
anf001 ap.doc•10/02
Asbestos Notification Form•Page 1 of 3 •
1 Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
0
0
o 1. Current or prior use of facility:
•
100184533
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 duds(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
166
b. l otal other surfaces(square fl)
Lin.1t
Lin.ft.
Lin.ft.
Lin.ft.
6
Sq.ft.
5q.ft.
Lin.11.
d.Insulating cement
f Trowel/Sprayer coatings
h Transits board,wall board
j.Other,please specify:
CAULK
Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used:
Lin.ft.
Lin.ft.
Lin.ft.
6
Lin.ft.
100
Sq.ft.
Sq.fl.
(60
Sq.ft.
Sq.fl.
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:
a.N
a.Name of DEP Official
c.Date(mm/dd/yyyy)of Authorization
IN/A
e Name of DOS Official
g.Date(mm/tltltyyyy)of Authorization
b TNe
IN/A
d.DEP waiver#
f.DOS Official Title
N/A
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❑ No
B. Facility Description
0
HOUSING
2. Is the facility owner-occupied residential with 4 units
3.
0
u. 4
Z
(NORTHAMPTON HOUSING AUTHORITY
a.Facility Owner Name
NORTHAMPTON
c.City/Town
01060
d.Zip Code
BILL CELATKA/B-G MECHANICAL SERVICE,
a.Name of Feebly Owners On-Site Manager
'CHICOPEE
c.City/Town
anf001 ap.doc•10/02
01020
d.Zip Code
or less? ❑Yes
No
49 OLD SOUTH STREET
b.Address
413-584.4030
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 1.
Li Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
ote:Transfer
[aliens must
Amply with the
olid Waste
ivision
egulations 310
MR 19.000
100184533
Decal Number
B. Facility Description (cont.)
5' a.Name of General Contractor
BILL CELATKA/B-G MECHANICAL SERVICE,
CHICOPEE
c.City/Town
01020
d.Zip Code
f.Contractors Worker's Comp.Insurer
6. What is the size of this facility?
12 SECOND AVENUE
b.Address
413-888-1500
e.Telephone Number(area cod and extension)
g.Policy Number h.Exp.Date(mm/dd/yyyy)
b.Number of floors
1800
a Square Feet
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
ABIDE, INC.
a.Name of Transporter
(EAST LONGMEADOW
c.City/Town
01028
d.Zip Code
P.O. BOX 886
b.Address
4135250644
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
TRANSWASTE, INC.
a.Name of Transporter
IWALLINGFORD,CT
c.City/Town
3. IN/A
a.Refuse Transfer Station and Owner
4.
06492
d.Zip Code
c Citvrrown
d.Zip Code
MINERVA ENTERPRISES INC
a Final Disposal Site Location Name
19000 MINERVA ROAD
c.Final Disposal Site Address
OH
e.State
eo
° D. Certification
The undersigned hereby states,under the
p It f perjury,that he/she has read the
C o Ith f M h tt g let s
for the Removal, Containment or
r 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 f.
nowledge and belief
°(��
l`Q�.
z
44688
f.Zip Code
3 BARKER DRIVE
b.Address
2032697300
e.Telephone Number
b.Address
e.Telephone Number
b.Final Disposal Site Location Owners Name
IWAYNESBURG
d.City/Town
g Telephone Number
an10D1 ap.doc•10/02
MARIA TILL(
a.Name
PRESIDENT
c.Position/Title
4135250644
e.Telephone Number
IP.O. BOX 886
q.Address
(EAST LONGMEADOW 1
h.City/Town
Maria Tilli
b.Authorized Signature
8/30/2013
d.Date(mm/dd/vwv)
(ABIDE, INC.
L Representing
01028
i.Zip Code
Asbestos Notification Form•Page 3 of 3 IN