124-131 Asbestos Notification Form 2013 Important:
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only the lab key
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100184538 Qy,oyyy3}
Decal Number VV
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A. Asbestos Abatement Description
a. Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied
residence of four units or less? 4 Yes ❑ No
b. Provide blanket decal number if applicable:
2. Facility Location:
INSTRUCTIONS 3
1.NI sections of this
f ml must be
completed in order
t comply with 4
EP notification
requirements of 310 5
CMR 7.15
nd the Division
(Occupational
afety(DOS)
otification
r guirements of 453
MR 612
0
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0
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6
7
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NHA-FORSANDER APARTMENTS, BLDG 0 1
a.Name of Facility
Northampton
c.City/Town
Worksite Location:
NHA-FORSANDER APTS.
MA
d.State
0
a.Building Name/Building Location b.Building it
Is the facility occupied? Fl Yes ❑ No
Asbestos Contractor:
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.Fadlity Contact Person
CHRISTOPHER J.COOPEE
a.Name of On-Site Supervisor/Foreman
'IBA
a.Name of Project Monitor
ITBA
a.Name of Asbestos Analytical Lab
19/23/2013
a.Project Start Date(mmldd/yyyy)
7AM-5PM
c.Work hours Mon-Fn.
10. a.What type of project is this?
❑ Demolition Renovation
❑Repair ❑ Other, please specify:
11. a. Check abatement procedures:
O Glove bag
❑❑Enclosure
Cleanup
Full containment
0
12. Is the job being conducted:
■ anroolapdoc•10/02
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
I2
Blanket Decal Number
124-131 HIGH STREET
b Street Address
101062
e.Zip Code
c Wing
f.Telephone Number
d. Floor
MECHANICA
e Room
483 SHAKER ROAD
b.Address
4135250644
e.Telephone Number
g. Contract Type: ❑Written
0
Verbal
'GENERAL CONTRACTOR
i.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
19/23/2013
b.End Date(mnudd/yyyy)
d.Work hours Sat-Sun.
b Describe
b.Describe
Indoors? ❑Outdoors?
Asbestos Notification Form•Page 1 of 3
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100184538
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.Bailer.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.Total other surfaces(square ft)
Lin.ft.
Lin.ft.
Lin.ft.
Lin.ft
Lin.ft.
6
S d Insulating cement
Sq
Sq.ft.
f.Trowel/Sprayer coatings
h.Transite board,wall board
S ft j Other,please specify:
Lin.ft
Lin ft.
Lin.ft.
6
Lin ft.
100
Sa ft.
Sq.ft.
Sq.ft.
CAULK
Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used
Sq.h.
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:
N/A
a.Name of DEP Official
c.Date(mn dd/yyyy)of Authorization
N/A
e.Name of DOS Official
g.Date(mm/ddlyyyy)of Authorization
b.Title
1N/A
d.DEP Waiver k
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
1 Current or prior use of facility:
0
2. Is the facility owner-occupied residential with 4 units or less?
HOUSING
NORTHAMPTON HOUSING AUTHORITY
3' a.Facility Owner Name
° [NORTHAMPTON
c City/Town d Zip Code
'BILL CELATKA/B-G MECHANICAL SERVICE,'
LL 4
a.Name of Facility Owner's On-Site Manager
Z 1CHICOPEE
c.City/Town
01060
anPoptap.doc•te/02
01020
d.Zip Code
❑Yes
No
49 OLD SOUTH STREET
b.Address
413-584-4030
e.Telephone Number(area code and extension)
2 SECOND AVENUE
b.On-Site Manager Address
1413-888-1500
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
0
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a
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
00184538
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
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
2,000
a.Square Feet
h.Exp.Date(mmldd/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
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
WALLINGFORD,CT
c.City/Town
3. IN/A
a.Refuse Transfer Station and Owner
06492
d.Zip Code
c City/Town
4. [MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
'9000 MINERVA ROAD
c.Final Disposal Site Address
(OH
e.State
d.Zip Code
44688
f.Zip Code
13 BARKER DRIVE
b Address
12032698300
e.Telephone Number
b.Address
e.Telephone Number
b.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.
anf001ap doc•10/02
`MARIA TILL'
a.Name
'PRESIDENT
C.Position/Title
4135250644
e Telephone Number
'P.O. BOX 886
A.Address
[EAST LONGMEADOW
h.City/Town
Maria Tilli
b.Authorized Signature
18/30/2013
d.Date(mm/dd/vvvv)
'ABIDE, INC.
L Representing
101028
Zip Code
Asbestos Notification Form•Page 3 of 3•