95-97 Asbestos Notification Forms 2013 9/03/2013 TUE 12: 05 FAX +-P+ Northampton Board Health
Important
Wen Meg out
fame on the
computer,use
only to lab key
to move your
cursor-do net
use the return
key.
INSRUCUONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
®001/027
•
1100184533 m,arivi-
Decal Number'"•Y
boyet .59o989
A. Asbestos Abatement Description
1.
a Is this faciity fee exempt-cilytown,disbid, municipal housing authority,owner-occupied
residence of four units or less?101 Yes ❑No
b.Provide blanket decal number if applicable:
2. Facility Location:
NHA-FORSANDER APARTMENTS,BDILDIN
a.Name of Facility
'Northampton
c Citproen
1
3. Worksite Location:
I.AR swamis of no
tam Rust be
competed In order
to comply uwt 4
DEP rroaeraeot
repM1emmh al 310
CMR 7.15 5.
and Ile DMSon
of Ocoesim cal
safety 13051
notification
requirements of 453
CMR812
6.
7.
8.
9.
NHA-FORSANDER APTS.
MA
d.State
p
a.Baling Name/Burma Lmlpn b.Baud ga
Is the fadliy occupied? p Yes ❑No
Asbestos Contractor
ABIDE INC
a.Name
EAST LONGMEADOW
01028
Chffwm d.Zip Code
(AC000254
f.DOS License Number
BILL CELATKAIB-G MECHANICAL SERVICE,'
h.Family Pelson
'CHRISTOPHER J.COOPEE
a.Name aaLSee smen,sor/Fomman
NBA
a Name of Prated Monitor
!TEA
e.Name of Asbeebs Maydcal Lad
1911642013
a.anima sun pate Irmddmyyl l
17AM-5PM
a Work hags MamFA.
10 a What type of project is this?
❑Dameftion Fl rtu• ban
❑Repair ❑Other,please specify:
11. a.Check abatement procedures:
Glove bag
Enclosure
Cleanup
Full containment
❑Encapsulation
❑Disposal only
❑Other, specify:
Blanket Decal Number
84-91 HIGH STREET
b.Street Address
101062
a re Cale
f.Telphone Meter
d.Floor
MECHANCCA1
e.Room
483 SHAKER ROAD
b.Address
4135250644
a Telephone Number
g.Contract Type: ❑Written O Verbal
'GENERAL CONTRACTOR
I.Corded Persons TAE
1AS070247
b.SwrvisadFaeman DOS Certification Nuter
1N/A
b.Prated Morita DCA CeNgwbon timber
1WA
9716/2013
b.Bra Data(nawdd ,yYy)
d.work hours Sal-Ste.
b.Describe
b.Describe
12 Is the job being conducted: O Indoors? ❑Outdoors?
■ anAOlap.doc•10102
Asbestos Notficaticn Form•Pone 1 of 31
Io Bete(nmdddyyyY)aAUeo,rtaion
IWA
e.Name of DOS Official
15. Describe the containel¢afc&disposSl methods to campy with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
'ACM ADEQUATELY WETTED DOUBLE BAGGED,SFAI Fn AND LABELED
IWA
0.DEP Waiver*
if DOS OO®Irde
IWA
h.DOS Waiver
101020
d.Zip Code
3/2013 TO 12:06 FAX -^» Northampton Board Dearth
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
■
1100184533
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or
encapsulated:
16 '
a.Taal pipes or duds gamer A)
c.Baby.breathing.duct tank
surface coatings
e.Canopied or layered papa
pipe iaaabon
9.Sp ayon NewooMg
I.G 1hs,woven Talmo;
It
Thermal,solid core pipe
aeaeEOn
(166
b.l dal Mlle eumme(were r)
8
14. Describe the dewrdamination system(s)to be used:
d.Insulating cement
f Trowel/Sprayer coatings
h.Trartslte board.wall board
F Other,please sped
!CAULK
Sperdy
6
ft.
So.A
,REMOTE AND/OR CONTIGUOUS THREE STAGE DECONTAMINATION UNIT W/SHOWPR
1
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency.
IWA
a.Name of DEP oriole
II
b.Tae
g Date(mmldwymy)of Authorization
17. Do prevailing wage rates as per M.G.L.c.149,126.27 or 27A-F apply to this project?
Yes❑No
B. Facility Description
1. Current or prior use of facility:
2. Is the facilty owner-occupied residential with 4 units or less? ❑Yes
149 ow SOUTH STREET
b.Address
(HOUSING
(NORTHAMPTON HOUSING AUTHORITY 1
3. a.Fealty
!NORTHAMPTON
101060 I
a CINFInwn d.Il Code
!BILL CELATKNB•G MECHANICAL SERVICE,1
4 a Name of Fade),Owner's On oche Manager
'CHICOPEE
a Cbfffown
• ardent ap4ec•10.102
0
No
1413-5844030
e.Telephone Number(area code and edeeion)
112 SECOND AVENUE
b.On-Site Manger Address
1413-088.1800
e.Telephone Number(area code and extension)
Asbestos Notliwtlon Form•Page 2 of •
1CHICOPEE
c.CltylTown
b.Address
1413-08 6150 0
e.Telephone Number(area li co&and extension)
h.Ent.Date trigne Nnyyy)
1 tib.Minter cif loons
12032697300
e Telephone Number
II
b.Address
3/2013 TOE 12:07 FAX -•-. Northampton Hearn eeaicn
Note:Transfer
Salons meet
comply SorrelWaste
Division
Regulations 316
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100184533
Decal Number
B. Facility Description (cont.)
'BILL CELATKAIB-G MECHANICAL SERVICE,[
a.Name of General Contractor
101020 1
a.Zip Code
f.ComredWaNApkera Cane.lower
6. what is 0te size at this facility?
1
g.Policy Number
11800
a.Samara Feet
112 SECOND AVENUE
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(d necessary):
'ABIDE,INC.
a.Name of Transporter
'EAST LONGMEADOW
c.City/Tawm
101028 I
a.
Zip Code e.Telephone
'p 0.BOX 886
h Address
14135250644
2. Transporter of asbestos-containing waste material from removal'tanporary site to final disposal site:
1TRANSWASTE,INC.
a.Nana of Transporter
'WALLINGFORD,CT
c.Ciwraan
3. 'NIA
a.Refuse Transfer Station and Owner
06492
d.2p Code
a CibRawn
4 'MINERVA ENTERPRISES INC
a.Anal Dnoeal Sle Locelion Name
19000 MINERVA ROAD
c.Final 0.sposal Ste Address
1OH
e.State
13 BARKER DRIVE
b.Address
d.Za Code
1 I
Zip Code
e.Telephone Number
b.Final olspesal sae sears Owners Nave
'WAYNESBURG
d.Clwtawn
g.Telephone Number
Fes° D. Certification
a The udemigned hereby Mates.under the
° penellem of PMUry,that he/she hem read the
a Commormealh of Massatlxrse0s regulations
for the Removal,Containment or
• Encapsulation of Asbestos,453 CMR 8.00 and
310 CMR 7.15,and that the infarmatton
contained m this noti(ration m true and coned
o to the best of Mauler knowledge and be*f.
LL Work-
an1601ap.doe 10A2
'MARIA nW
1
a.Name
[PRESIDENT 1
c.PosSotose
14135250644 1
a Tel*Ohana Hunt.
'P.O.BOX 806
a.Address
'EAST LONGMEADOW
b.C1y7TOwn
'Maria Tdlt 1
b.Authorized Spnatue
18/3012013
d.Dale Cfnmiddtmeng
(ABIDE,INC.
I.ReaeseN9
101028
i.Zip Code
Asbestos Noelcalan Faun•Page 3 of 3•
portant:
ten filling out
ms on the
mputer,use
ly the tab key
move your
rsor-do not
e the return
STRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
Decal Number
thelCIS
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? 0 Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
'NBA-FORSANDER APARTMENTS, BLDG K
a Name of Facility
(Northampton
c City/Town
3. Worksite Location:
All sections of this
rat must be
impleted in order
comply with 4.
EP notification
quirements of 310
MR 7.15 5.
td the Division
Occupational
afety(DOS)
otircation
quirements of 453
MR 6.12
a
0
N
0
1NHA-FORSANDER APTS. 1
a.Building Name/Building Location
Is the facility occupied?
Asbestos Contractor:
l7
MA
d.State
b.Building#
Yes ❑No
'ABIDE INC
a.Name
'EAST LONGMEADOW
C.City/Town
01028
d.Zip Code
1AC000254
f.DOS License Number
'BILL CELATKAIB-G MECHANICAL SERVICE,
h Facility Contact Person
6 'CHRISTOPHER J.COOPEE
a. Name of On-Site Supervisor/Foreman
'TBA
7 x Name of Project Monitor
8 1TBA
a Name of Asbestos Analytical Lab
9. 19/17/2013
a. Project Start Date(mmlddlyyyy)
17AM-5PM
c.Work hours Mon-Fri.
10 a What type of project is this?
o ❑ Demolition 0 Renovation
❑Repair ❑Other, please specify:
0
LL
z
C
11. a. Check abatement procedures:
E Glove bag
Enclosure
❑Cleanup
Full containment
0
❑ Encapsulation
❑ Disposal only
❑Other, specify:
Blanket Decal Number
192-99 HIGH STREET
b.Street Address
01062
e.Zip Code
c.Wing
f.Telephone Number
d.Floor
MECHANICA
e.Room
483 SHAKER ROAD
14135250644
e.Telephone Number
g. Contract Type: ❑Written
b.Address
0
Verbal
'GENERAL CONTRACTOR
Contact Person's-"
1A5070247
b.Supervisor/Fore man DOS Certification Number
IN/A
b.Project Monitor DOS Certification Number
1N/A
b.Asbestos Analytical Lab DOS Certification Number
'9/17/2013
b.End Date(mm/ddlyyyy)
d.Work hours Sat-Sun.
b.Describe
b.Describe
12. Is the job being conducted: IN Indoors? ❑Outdoors?
anf001ap.doc•10/02
Asbestos Notification Form•Page 1 of 3 II
IN/A
g.Date(mm/ddlyyyy)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?
0
N
0
0
0
LL
z
C
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100184534
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed, or
encapsulated:
Ia 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
166
b.Total other suffices(square ft)
Lin.fl.
Lin.ft.
Lin.fl.
6
Sq.ft.
Sq n.
Sq.fl.
Lin.ft.
S ft
d.Insulating cement
f.Trowel/Sprayer coatings
h.Transite board,wall board
j.Other,please specify.
[CAULK
Sq ft. t.Specify
14. Describe the decontamination system(s)to be used:
Lin.It
Lin.ft.
Lin.ft.
6
Lin.ft.
100
Sq.fl.
Sq.ft.
(60
Sq.ft.
Sq.ft.
[REMOTE AND/OR CONTIGUOUS THREE STAGE DECONTAMINATION UNIT WISHOWER
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:
N/A
a.Name of DP Official
c.Date(mmlddlyyn)of Authorization
IN/A
e.Name of DOS Official
b.Title
INA
d.DEP Waiver it
T.DOS Official Title
Yes❑ No
B. Facility Description
1 Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or less9 ❑Yes
149 OLD SOUTH STREET
'HOUSING
(NORTHAMPTON HOUSING AUTHORITY
3' a.Facility Owner Name
NNORTHAMPTON
No
b.Address
101060
c.City/Town d.Zip Code
[BILL CELATKA/B-G MECHANICAL SERVICE,
4' a.Name of Facility Owner's On-Site Manager
(CHICOPEE
c.City/Town
• anf001ap.doc•10/02
101020
d.Zip Code
1413-5843030
(
e.Telephone Number(area code and extension)
112 SECOND AVENUE
b.On-Site Manager Address
1413-888-1500
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3•
ote:Transfer
tations must
amply with the
olid Waste
ivision
egulations 310
MR 19.000
CO
0
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100184534
Decal Number
B. Facility Description (cont.)
5 (BILL CELATKA/B-G MECHANICAL SERVICE,
a.Name of General Contractor
!CHICOPEE
c.City/Town
101020
d Zip Code
12 SECOND AVENUE
b.Address
413-888-1500
I I
f.Contractor's Workers Comp.Insurer
6. What is the size of this facility?
e.Telephone Number(area code and extension) 1
h.Exp.Date(mm/dd/yyyy)
I 12 I
b.Number of floors
q.Policy Number
(1,800
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
101028
'P.O. BOX 886
b.Address
14135250644
c.City/Town d.Zip Code e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
(TRANSWASTE, INC.
a.Name of Transporter
!WALLINGFORD, CT
c.City/Town
3. IN/A
a.Refuse Transfer Station and Owner
106492
d Zip Code
c.City/Town
4. !MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
19000 MINERVA ROAD
C.Final Disposal Site Address
10F1
e.State
3 BARKER DRIVE
b.Address
12032698300
e.Telephone Number
b.Address
d.Zip Code
e.Telephone Number
144688
f.Zip Code
b.Final Disposal Site Location Owners Name
!WAYNESBURG
d.Citynown
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 beet
° C Kir\ii5c:NP19
LL
z
anf001ap doc•10/02
(MARIA TILL'
a.Name
'PRESIDENT
C.Position/Title
14135250644
e.Telephone Number
(P.O. BOX 886
q.Address
(EAST LONGMEADOW 1
h.City/Town
'Maria Tilli
b.Authorized Signature
18/30/2013
d Date Imm/dd/ww)
'ABIDE, INC.
f.Representing
101028
Zip Code
Asbestos Notification Form•Page 3 of 3 iU
rportanL
hen filling out
rms on the
mputer,use
rly the tab key
move your
irsor-do not
re the return
ry
ISTRUCTIO S
All sections of this
mr must be
impleted in order
comply with
EP notification
rpuirements of 310
MR 7.15
id the Division
I Occupational
afety(DOS)
cancation
iquirements of 453
MR 612
0
0
N
0
0
LL
Z
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100184535,Thwi 1F
Decal Number .�1
o,ti‘a•59101
A. Asbestos Abatement Description
1. a. Is this facility fee exempt-cites,town,district, municipal housing authority,owner-occupied
residence of four units or less? L Yes ❑No
b.Provide blanket decal number if applicable:
2. Facility Location:
INHA•FORSANDER APARTMENT, BLDG L I
a.Name of Facility
(Northampton
c.Clty/Town
3. Worksite Location:
INHA-FORSANDER APTS.
a.Building Name/Building Location
4. Is the facility occupied?
5. Asbestos Contractor:
6.
7.
8.
9
N
MA
d State
L
b.Building it
Yes ❑No
Blanket Decal Number
1100-107 HIGH STREET
b.Street Address
01062
e.Zip Code
[ABIDE INC
a. Name
101028
[EAST LONGMEADOW I I
c.City/rown d.Zip Code
1AC000254
f DOS License Number
[BILL CELATKA/B-G MECHANICAL SERVICE,(
c Wing
f Telephone Number
d.Floor
MECHANICA
e.Room
483 SHAKER ROAD
b.Address
4135250644
e.Telephone Number
g. Contract Type: ❑Written
Verbal
GENERAL CONTRACTOR
1.Contact Person's Title
[CHRISTOPHER J.COOPEE
I 1AS070247
a.Name of On-Site Supervisor/Foreman
b.Supervisor/Foreman DOS Certification Number
ITBA
IN/A
Name of Project Monitor
b.Project Monitor DOS Certification Number
a.
ITBA
I IN/A
a.Name of Asbestos Analytical Lab
b.Asbestos Analytical Lab DOS Certification Number
`9/18/2013
[ 19/18/2013
Project Start Date(mm/dd/yyyy)
End Date(mmfddlyyyy)
a.
17AM-5PM
(b.
IA
M1n,ms Sat-Sun.
c.Work hours Mon-Fri.
10. a.What type of project is this?
❑ Demolition N Renovation
❑ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
N
Glove bag
❑ Enclosure
❑Cleanup
Full containment
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
b.Describe
b.Describe
12. Is the job being conducted: IN Indoors? ❑Outdoors?
anf001ap.doc•10/02
Asbestos Notification Form•Page 1 of 3 U
°
°
N
0
0
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
'100184535
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 ducts(linear ft)
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
[166
b. I ofal other surfaces(square ft)
Lin.ft
Lin.fl
6
Sq.ft
Sq.ft
Lin.ft
Sq ft
Lin fl.
O.Insulating cement
f.Trowel/Sprayer coatings
h.Transite board,wall board
j.Other,please specify:
Lin.ft.
Lin.fl.
Lin.ft.
6
100
Sq.ft.
[60
Sq.ft.
14. Describe the decontamination system(s)to be used:
'REMOTE AND/OR CONTIGUOUS THREE STAGE DECONTAMINATION UNIT W/SHOWER
15. Describe the containerization/disposal methods to comply
6.14(2) (g):
ACM ADEQUATELY WETTED, DOUBLE BAGGED,SEALED AND LABELED
h 310 CMR 7.15 and 453 CMR
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
NIA
a.Name of DEP Officia
c.Date(mmlddlyyyy)of Au
rization
(NIA
e Name of DOS Office
g. Date(mm/dd/yyyy)of Authorization
17. Do prevailing wage rates as per M.G.L. c. 149, §26,27 or 27A—F apply to this project?
b.Title
N/A
d.DEP Waiver
f DOS Official Title
IN/A
h.DOS Waiver a
Yes ❑ No
B. Facility Description
1 Current or prior use of facility:
2. Is the facility owner-occupied residential
HOUSING
h 4 units or less?
INORTHAMPTON HOUSING AUTHORITY I
3 a.Facility Owner Name
° 'NORTHAMPTON
LL 4
2
Q
(
'01060
U.
City/Town d.Zip Code
'BILL CELATKA/B-G MECHANICAL SERVICE,'
a.Name of Facility Ownees On-Site Manager
'CHICOPEE
c.Cityrrown
1 anf001ap.doo•10/02
01020
d.Zip Code
❑Yes
No
49 OLD SOUTH STREET
b.Address
413-584-4030
e.Telephone Number(area code and extension)
112 SECOND AVENUE
b.On-Site Manager Address
'413-888-1500
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3 II
14135250644
e.Telephone Number
rte:Transfer
ations must
imply with the
'lid Waste
vision
:gulations 310
NR 19.000
0
0
0
a
0
LL
Z
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
00184535
Decal Number
B. Facility Description (cont.)
'BILL CELATKA/B-G MECHANICAL SERVICE,
5. a.Name of General Contractor
(CHICOPEE
c City/Town
101020
d.Zip Code
f Contractor's Workers Comp.Insurer
6. What is the size of this facility?
112 SECOND AVENUE
b.Address
1413-888-1500
e.Telephone Number(area code and extension)
g.Policy Number
'1,800
a.Square Feet
h.Exp.Date(mm/dd/yyyy)
I 12
b Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
ABIDE, INC.
a.Name of Transporter
'EAST LONGMEADOW
c City/Town d.Zip Code
01028
P.O. BOX 886
b.Address
14135250644
e.Telephone Number
2. Transporter of asbestos-Containing waste material from removal/temporary site to final disposal site:
13 BARKER DRIVE
b.Address
1TRANSWASTE, INC.
a.Name of Transporter
'WALLINGFORD,CT
c.City/Town
3. 1N/A
a.Refuse Transfer Station and Owner
06492
d Zip Code
12032698300
e.Telephone Number
c.City/Town
4. [MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
19000 MINERVA ROAD
C.Final Disposal Site Address
'OH
e.State
d.Zip Code
b.Address
44688
f.Zip Code
e.Telephone Number
�Final Disposal Site Location Owners Name
[WAYNESBURG
d City/Town
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.
O(-3tr\- j91001
an1001ap.doc•10/02
'MARIA TILLI
a.Name
'PRESIDENT
c Position/Title
'Maria Tllli
b.Authorized Signature
8/30/2013
d Date(mm/dd/VVWl
'ABIDE, INC.
f Representing
P.O. BOX 886
g.Address
'EAST LONGMEADOW I
h.City/Town
101028
Zip Code
Asbestos Notification Form•Page 3 of 3
'GENERAL CONTRACTOR
i.Contact Person's Title
portant:
nen filling out
ms on the
mputer,use
ly the tab key
move your
rsor-do not
e the return
STRUCTIO S
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
■
11 0 01 84 53 6 0Y p vvonoj
Decal Number 5Qi_ .\
o;)1(. S I v11
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? 0 Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
NHA-FORSANDER APARTMENTS, BLDG M
a Name of Facility
'Northampton
C.City/Town
3. Worksite Location:
AM sections of this
ml must be
mpleted in order
comply with 4.
EP notification
quirements of 310
MR 7.15 5.
,d the Division
Occupational
sfety(DOS)
**ration
quirements of 453
MR 6.12
INHA-FORSANDER APTS.
a.Building Name/Building Location
Is the facility occupied?
Asbestos Contractor:
F'
MA
d.State
M
b.Building#
Yes ❑No
ABIDE INC
a.Name
'EAST LONGMEADOW
c.City/Town
01028
d.Zip Code
1AC000254
f DOS License Number
BILL CELATKAIB-G MECHANICAL SERVICE,
h.Facility Contact Perso
6 'CHRISTOPHER J. COOPEE
a.Name of On-Site Supervisor/Foreman
TBA
7 a.Name of Protect Monitor
Blanket Decal Number
108-115 HIGH STREET
b.Street Address
01062
e Zip Code
C.Wng
f.Telephone Number
d.Floor
MECHANICA
e.Room
1483 SHAKER ROAD
b.Address
14135250644
e.Telephone Number
g. Contract Type: ❑Written
8
TBA
a.Name of Asbestos Analytical Lab
19/19/2013
o 9 a.Project Start Date(mMdd/yyyy)
o 17AM-5PM
c.VVork hours Mon-Fri.
N
Verbal
AS070247
b.Supervisor/Foreman DOS Certification Number
N/A
b.Project Monitor DOS CeNfication Number
N/A
b.Asbestos Analytical La
S Certification Number
9/19/2013
b.End Date tmrwdd/yyyy)
o 10 a What type of project is this?
° ❑ Demolition F' Renovation
❑Repair ❑Other, please specify:
11. a. Check abatement procedures:
° ❑v Glove bag
o ❑ Enclosure
• ❑ Cleanup
Full containment
z
• 12. Is the job being conducted: A Indoors? ❑Outdoors?
❑Encapsulation
❑ Disposal only
❑Other, specify:
d.Work hours Sat-Sun.
b.Describe
b.Describe
Asbestos Notification Form•Page 1 of 3
anf001ap.doo•10/02
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100184536
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
I6 1 '166 I
a.Total pipes or ducts(Imear ft) b. total other surfaces(square ft)
c.Boiler,breaching,duct,tank d.Insulating cement
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
Lin.ft
Lin.ft.
Lin.ft.
6
Sq.ft.
Sq.ft.
Lin.ft
Lin.ft.
Sq.ft.
Sq.ft.
14. Describe the decontamination system(s)to be used
1.Trowel/Sprayer coatings
h.Transite board,wall board
j.Other,please specify:
[CAULK
I.Specify
Lin.ft.
Lin.ft.
Lin.ft.
6
Lin.ft.
100
Sq.ft.
Sq.ft.
160
Sq.ft
Sq.ft.
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:
1N/A
a.Name of DEP Cffidal
c.Date(mm/dtllyyyy)of Authorization
[N/A
e.Name of DOS Offidal
b.Title
N/A
d DEP Waiver#
DOS Official Title
IN/A
g.Date(mmlddfyyyy)of Authorization h.DOS Waiver#
N
o 17 Do prevailing wage rates as per M.G.L. c. 149, §26,27 or 27A—F apply to this project? p Yes❑No
B. Facility Description
o 1 Current or prior use of facility:
0
0
LL
Z [CHICOPEE
Q c.City/Town
1NORTHAMPTON
'HOUSING
2. Is the facility owner-occupied residential with 4 units or less?
'NORTHAMPTON HOUSING AUTHORITY 1 149 OLD SOUTH STREET
3. a.Facility Owner Name
❑Yes
No
01060
C.CM/Town d.Zip Code
(BILL CELATKA/B-G MECHANICAL SERVICE,I
4. a Name of Facility Owners On-Site Manager
101020
d.Zip Code
I anf001ap.doc•10102
b.Address
1413-5844030
e.Telephone Number(area code and extension)
112 SECOND AVENUE
b.On-Site Manager Address
1413-888-1500
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3 N
de'Transfer
ations must
mply with the
did Waste
vision
egulations 310
NR 19.000
m
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
00184536
Decal Number
B. Facility Description (cont.)
(BILL CELATKA/B-G MECHANICAL SERVICE,'
5. a.Name of General Contractor
'CHICOPEE
c.City/Town
1
01020
d Zip Code
I.Contractors Workers Comp.Insurer
6. What is the size of this facility?
12 SECOND AVENUE
b.Address
413-888-1500
e.Telephone Number(area code and extension)
g.Policy Number
1,800
a.Square Feet
h.Exp.Date(mm/dd/yyyy)
2
b.Number of floors
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 d.Zip Code e.Telephone Number
waste material from removal/temporary site to final disposal site:
01028
P.O. BOX 886
O.Address
14135250644
2. Transporter of asbestos-containing
1TRANSWASTE, INC.
a.Name of Transporter
'WALLINGFORD, CT
c.City/Town
3. IN/A
a.Refuse Transfer Station and Owner
06492
d.Zip Code
a City/Town
4. 'MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
19000 MINERVA ROAD
c.Final Disposal Site Address
10H
e.State
3 BARKER DRIVE
b.Address
2032698300
e.Telephone Number
I1
b.Address
d.Zip Code
e.Telephone Number
144688
f Zip Code
b.Final Disposal Site Location Owners Name
WAYNESBURG
d.City/Town
g.Telephone Number
D. Certification
N
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
o to the best of his/her knowledge and belief.
o 06Cr\59l Jl l
LL
Z
anf001ap.doc•10/02
'MARIA TILL(
a.Name
PRESIDENT
c.PositioNiitle
14135250644
e.Telephone Number
Maria Tilli
b.Authorized Signature
18/30/2013
d.Date(mm/dd/yvvl
[ABIDE,INC.
Representin
P.O. BOX 886
q.Address 1
'EAST LONGMEADOW
h.City/Town
101028
Zip Code
Asbestos Notification Form•Page 3 of 3 II
13/2013 TUE
Important
When Ming out
forms on me
use
only the tab key
to move your
maser-do not
use the mtum
key.
I STRICTIONS
B FAX --- Northampton Board Health
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
Wd
I100164537pyo�
DeS Number
ptilcoak5910110
1 At 6eotb5 or this
rain must be
competed in order
to comply web
DEP notification
requirements
01510
M 7.15
and
de Division
or Occupational
S.rdyIDOSI
notification
requienwrns 01453
CUR 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 less? O Yes ❑No
b.Provide blanket decal number if applicable:
2. Facility Location:
INNA-FORSANDER APARTMENTS,BLDG N
a.Name or Fadf
!Northampton
c City/Town
3. Worksie Location:
INHA-FORSANDER APTS. I
a.Building Nemw&&rn8 Local.% b.Buidalg
4. Is the facility occupied? 4 Yes ❑No
MA
d.State
IN I
5. Asbestos Contractor
(ABIDE INC
a Name
EAST LONGMEADOW
c Ca y/fown
IAC000254
r ms License Number
IBILL CELATKAIB-G MECHANICAL SERVICE,I
h Family Contact Person
!CHRISTOPHER J.COOPEE
6• a Name of OnSt Su ervisor/Fareman
BA
7' a.Name of Project Monitor
6 1TBA
a.Name of Asbestos Analytical Lab
B 19/2012013
a.Project Stmt Date twavd wyw
17AM-5PM
Work hours Mal-Fri
101026 1
4.2p Code
la a.What type of project is this?
❑Demolition ri Renovation
❑Repair ❑Other,please specify'
11. a.Check abatement procedures:
Lit Glove bag
Enclosure
Cleanup
Full containment
®Encapsulation
Disposal only
0 Other,specify.
Blanket Decal Number
1116-123 HIGH STREET
e.Zip Cade
lee
fT
d.Floor
MECHANICA
0.Room
1463 SHAKER ROAD
b.Addles
14135250644
a.Teipte a Number
9. Contract Type: ❑Written
Verbal
!GENERAL CONTRACTOR
I.Cabo Peaowsme
1AS070247
b.SuperviconFammn DOS CeNfialian Number
IN/A
b.Projetl Monitor DOS Certification Number
IN/A
D Asbestos Analytical Lab DOS Certification NumDef
1912012013
b.End Da(ma/d4nyyyyl
(
Work Kowa Sat-site.
b.Describe
b.Descnie
12. Is the job being conducted: 12 Indoors? ❑Outdoors?
■ anmOlapdoc•10/02
Asbeitus Notification Firm•Pape 1 of a■