140-147 Asbestos Nofitication Form 2013 mportant
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100184544�yp *
Decal Number
011 � .59I95
A. Asbestos Abatement Description
1. a. Is this facility fee exempt-citytown, district, municipal housing authority, owner-occupied
residence of four units or less? !HI Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
ISTRUCTIO S 3
All sections a@ s
wm must be
mpleted in order
comply ydth 4
EP notification
quirements of 310
MR7.15 5
id the Division
IOccupational
afety(DOS)
otineation
quirements of 453
MR 6.12
6.
T a. Name of Project Monitor
'TBA
6' a.Name of Asbestos Analytical Lab
19/25/2013
O 9 a.Project Start Date(mn/ddryyyy)
NHA-FORSANDER APARTMENTS, BLDG Q
a Name of Faddy
Northampton
c.City/Town
Worksite Location:
NHA-FORSANDER APTS
a. Building Name/Building Location
Is the facility occupied?
Asbestos Contractor:
17
MA
d.State
Q
b.Building#
Yes ❑No
ABIDE INC
a.Name
EAST LONGMEADOW
n City/Town
01028
d.Zip Code
AC000254
L DOS License Number
BILL.CELATKA/B-G MECHANICAL SERVICE,
h.Faddy Contact Person
CHRISTOPHER J.COOPEE
a.Name of On-Site Supervisor/Foreman
TBA
0
o Glove bag
o ❑ Enclosure
❑Cleanup
Full containment
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:
14
Z
14
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
Blanket Decal Number
140-147 HIGH STREET
b.Street Address
01062
e Zip Code
0.
Ing
f.Telephone Number
d
Floor
MECHANICA
e Room
483 SHAKER ROAD
b.Address
4135250644
e.Telephone Number
g. Contract Type: ❑Written
Verbal
(GENERAL CONTRACTOR
I.Contact Person's TNe
AS070247
b.Supervisor/Foreman DOS Certification Number
1N/A
b.Project Monitor DOS Certification Number
N/A
b.Asbestos Analytical Lab DOS Cerification Number
9/25/2013
b.End Date(mmldd/yyyy)
d.Work hours Sat-Sun.
b.Desc be
b.Describe
12. Is the job being conducted: Q Indoors? ❑Outdoors?
anf001 ap.doc•10/02
Asbestos Notification Form•Page 1 of 3
L 1Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100184544
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,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 surfaces(square ft)
Lin.ft
Lin.ft
Lin.ft
Lin.ft
Lin.ft.
6
Sq.ft.
Sq ft
Sq.f
d. Insulating cement
f.Trowel/Sprayer coatings
h.Transite 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.
ft.
6
Lin.ft.
100
Sq
Sq.ft
'60
Sq ft.
Sq.0.
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(mm/dd/yyyy)of Authorization
N/A
e.Name of DOS Offidal
g.Date(mm/dd/yyyy)of Authorization
b.Title
N/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
o B. Facility Description
O 1. Current or prior use of facility:
0
0
z
'HOUSING
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes
3
'NORTHAMPTON HOUSING AUTHORITY
a Faddy Owner Name
NORTHAMPTON
1 101060
c.CM/Town d.Zip Code
4 'BILL CELATKA/B-G MECHANICAL SERVICE,'
a.Name of Facility Owner's On-Site Manager
'CHICOPEE
c.City/Town
an1001 ap doc•10/02
01020
d.Zip Code
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•
ste:Transfer
ations must
imply with the
'lid Waste
vision
>gulations 310
0R 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100184544
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.Contractor's Worker's Comp.Insurer
6. What is the size of this facility?
12 SECOND AVENUE
b.Address
1413-888-1500
1 e.Telephone Number(area code and extension)
g Policy Number h.Exp.Date(mm/dd/yyyy)
12,000
a.Square Feet
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 removaUtemporary site to final disposal site:
TRANSWASTE, INC.
a Name of Transporter
'WALLINGFORD,CT
c.City/Town
3. N/A
a.Refuse Transfer Station and Owner
4
06492
d.Zip Code
c.CM/Town
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
3 BARKER DRIVE
h.Address
2032698300
e Telephone Number
lb Address
e.Telephone Number
b.Final Disposal Site Location Owners Name
'WAYNESBURG
d.City/Town
q.Telephone Number
• D. Certification
The undersigned hereby states, under the
p a8 of perjury,that he/she has read the
C Ith fM h 8 g if
f th R IC t t
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15, and that the information
c ta' ed th's officato 'st d o ct
• t th b t f h's/h k I dg db f f
o r‘ I 4 .51 vM5
LL
Z
anf00lap.doc•10/02
MARIA TILLI
a.Name
PRESIDENT
c.Positioraitle
4135250644
e.Telephone Number
Maria Tilli
b.Authorized Signature
8/30/2013
d.Date(mm/dd/vvw)
ABIDE, INC.
f.Representing
P.O. BOX 886
g.Address
'EAST LONGMEADOW 1
h.City/Town
101028
i Zip Code
Asbestos Notification Form•Page 3 of 3 U