97 Asbestos Notification Form 2010 Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
cAl
INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form Aii - 01'
100114969
Decal Number
•
A. Asbestos Abatement Description
t•
1. a. Is this facility fee exempt-city, town,district, municipal hotting authority, owner-occupied
residence of four units or less? GI Yes ❑No
b.Provide blanket decal number if applicable:
2. Facility Location:
HAMPSHIRE HEIGHTS
a.Name of Facility
Northampton
c.City/Town
3. Worksite Location:
1.All sections of tits
form must be
completed in order
to comply with 4
DEP notification
requirements of 310
CMR 7.15 5
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 6.12
6
7
8
9
HAMPSHIRE HEIGHTS
a.Building Name/Building Location
MA
d.State
17
b.Building k
Is the facility occupied? Ti Yes ❑ No
Asbestos Contractor:
ACCUTECH INSULATION & CONTRACTING I
a.Name
LUDLOW
c.City/Town
01056
d.Zip Code
AC000005
f.DOS License Number
DOUGLAS COURTEMANCHE
h.Facility Contact Person
DOREY L. BESAW
a.Name of On-Site Supervisor/Foreman
N/A
a.Name of Pmiect Monitor
N/A
a.Name of Asbestos Analytical Lab
1/10/2011
a.Project Start Date(mm/dd/yyyy)
SAM -4PM
c.Work hours Mon-Fn.
0 10 a What type of project is this?
0
0
LL
Z
❑ Demolition 0 Renovation
❑ Repair ❑Other, please specify:
11. a. Check abatement procedures:
12
Glove bag
❑ Enclosure
❑Cleanup
❑ Full containment
12. Is the job being conducted:
anf001ap.doc•10/02
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
Blanket Decal Number
97 HAWLEY STREET
b.Street Address
101060
e.Zip Code
J
c.Wing
14077372000
f.Telephone Number
O.Floor
e.Room
100 STATE STREET
b.Address
[4135835500
e.Telephone Number
g. Contract Type:
0
Written ❑Verbal
PROJECT MANAGER
i.Contact Person's Title
AS071928
b.Supervisor/Foreman DOS Certification Number
N/A
b.Project Monitor DOS Certification Number
IN/A
b.Asbestos Analytical Lab DOS Certification Number
1/10/2011
b.E nd Date(mm/dd/yyyy)
N/A
d.Work hours Sat-Sun.
b.Describe
b.Describe
Indoors? U Outdoors?
Asbestos Notification Form•Page 1 of 3 S
LCommonwealth Mu
Asbestos Notification assachsett s Form ANF-001
•
100114909
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed,enclosed, or
encapsulated:
0
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
b. I otal other surfaces(square ft)
Lin.ft
Lin.ft.
Lin.ft.
Lin.ft.
Lin.ft.
Sq ft
Sq.ft.
Sq.ft.
S
ft.
Sq.ft.
14. Describe the decontamination system(s)to be used:
d.Insulating cement
f.Trowel/Sprayer coatings
h Transite board,wall board
j.Other,please specify:
I.Specify
Lin.ft.
Lin.ft.
Lin.ft.
Lin.ft.
1
Sq.ft.
Sq.ft.
Sq.ft.
SEAL CRITICALS W/6MIL POLY, PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NEG
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 A SEALED VEHI
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
a.Name of DEP Offcia
c.Date(mm/dd/yyyy)of Authorization
b.Title
d.DEP Waiver#
e.Name of DOS Official
g.Date(mm/dd/yyyy)of Authorization
( DOS 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? • Yes❑ No
B. Facility Description
0 1 Current or prior use of facility:
0
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes
RESIDENTIAL
O
0
u. 4.
Z
3.
HAMPSHIRE HEIGHTS
a.Facility Owner Name
NORTHAMPTON
c.City/own
01060
d.Zip Code
DOUGLAS COURTEMANCHE
a.Name of Facility Owner's On-Site Manager
WARWICK
'C c.City/Town
an(001ap doc•10/02
02886
d.Zip Code
No
97 HAWLEY STREET
b.Address
401-737-2000
e.Telephone Number(area code and extension)
3600 WEST SHORE ROAD
b.On-Site Manager Address
401-737-2000
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3 S
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
cv
0
0
0
LL
Z
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100114909
Decal Number
B. Facility Description (cont.)
5.
NATIONAL REFRIGERATION
a.Name of General Contractor
WARWICK
c.City/Town
02886
d.Zip Code
AIG
f.Contractors Worker's Comp.Insurer
6. What is the size of this facility?
3600 WEST SHORE ROAD
b.Address
401-737-2000
e.Telephone Number(area code and extension)
I W C 5312904 111/4/2010
r.Policy Number h.Exp.Date(mr dd/yyyy)
a.Square Feet 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 &CONT., INC.
a.Name of Transporter
LUDLOW
c.City/Town
01056
d.Zip Code
100 STATE ST. BLDG 119 PO BOX 376
b.Address
4135835500
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
3
4
RED TECHNOLOGIES
a.Name of Transporter
BLOOMFIELD
c.City/Town
06002
d.Zip Code
10 NORTHWOOD DRIVE
b.Address
8602182428
e.Telephone Number
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
L Zip Code
b.Address
e.Telephone Number
b.Final Disposal Site Location Owner's 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
ta'ned in this tfcat on is Ir ea do t
to the best of his/her knowledge and belief.
anf001ap.doc•10/02
FAITH LEMAY
a.Name
IADMIN ASST
c.Position/Title
4135835500
F h LeMay
Authorized Signature
10/15/2010
d.Date(mm/ddlyyry)
e.Telephone Number f.Representing
1100 STATE ST. BLDG 119 PO BOX 376
q.Address
LUDLOW
h.City/Town
01056
i.Zip Code
Asbestos Notification Form•Page 3 of 3 N
[-----
0 Asbestos Notification Form ANF-001
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
Commonwealth of Massachusetts
■
100114915
Decal Number
A. Asbestos Abatement Description
a. Is this facility fee exempt-ci'town,district, municipal housing authority, owner-occupied
residence of four units or less?u Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
HAMPSHIRE HEIGHTS
a.Name of Facility
NORTHAMPTON
c.City/Town
3. Worksite Location:
1.All sections of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR 7.15 5.
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 6.12
HAMPSHIRE HEIGHTS
a.Building Name/Building Location
Is the facility occupied?
Asbestos Contractor:
n
LMA
d.State
Blanket Decal Number
97 HAWLEY STREET
b.Street Address
I 101060
e.Zip Code f.Telephone Number
10C & 10D
b.Building p
Yes ❑ No
ACCUTECH INSULATION &CONTRACTING I
a.Name
LUDLOW
c.City/Town
01056
d.Zip Code
AC000005
f.DOS License Number
DOUGLAS COURTEMANCHE
h.Faulty Contact Person
DOREY L. BESAW
6. a.Name of On-Site Supervisor/Foreman
N/A
7. a.Name of Protect Monitor
IN/A
8. a.Name of Asbestos Analytical Lab
9 a.Project Start Date(mm/dd/yyyy)
12/9/2010
8AM -4PM
c.Work hours Mon-Fn.
10. a.What type of project is this?
0 ❑ Demolition Renovation
❑ Repair ❑ Other, please specify:
11, a. Check abatement procedures:
0
0
a
Z
n
Glove bag
❑ Enclosure
❑Cleanup
❑ Full containment
rt 12. Is the job being conducted:
anf001ap.doc•10/02
(, Encapsulation
❑ Disposal only
❑Other, specify:
4077372000
c.Wing
d.Floor
e.Room
100 STATE STREET
b.Address
4135835500
e.Telephone Number
g. Contract Type:
Written ❑Verbal
PROJECT MANAGER
Contact Person's Title
AS071928
b.Supervisor/Foreman DOS Certification Number
IN/A
b.Project Monitor DOS Certification Number
N/A
b.Asbestos Analytical Lab DOS Certification Number
12/9/2010
b.E nd Date(mm/dd/yyyy)
N/A
d.Work hours Sat-Sun.
b.Describe
b.Describe
Indoors? ❑Outdoors?
Asbestos Notification Form•Page 1 of 3 IN
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100114915
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed,enclosed, or
encapsulated:
0
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
I2
b. I otal other surfaces(square fl)
Lin.ft
Lin.ft.
Lin.ft.
Lin.ft.
Lin.ft.
Sq.ft.
Sq.ft.
Sq.ft.
d.Insulating cement
f.Trowel/Sprayer coatings
h.Transite board,wall board
j.Other,please specify:
Lin.ft.
ft.
Lin.ft.
ft.
2
Sq.ft.
Sq.ft.
Sq.ft.
Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used
SEAL CRITICALS W/6 MIL POLY,PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NEG
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& DELIVERED IN A SEALED VEHICL
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
a,Name of DEP Official
c.Date(mm/dd/yyyy)of Authorization
e.Name of DOS Official
g.Date(mm/dd/yyyy)of Authorization
b.Title
d.DEP Waiver#
f.DOS 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? p Yes❑ No
o B. Facility Description
O 1 Current or prior use of facility:
0
0
0
LL
Z
C
RESIDENTIAL
2. Is the facility owner-occupied residential with 4 units or less?
3. a.Facility Owner Name
INORTHAMPTON
HAMPSHIRE HEIGHTS
4.
c.City/Town
DOUGLAS COURTEMANCHE
01060
d.Zip Code
anfoolap.doc•10/02
a.Name of Facility Owner's On-Site Manager
WARWICK
c.City/Town
02886
d.Zip Code
❑Yes
No
97 HAWLEY STREET
b.Address
401-737-2000
e.Telephone Number{area code and extension)
3600 WEST SHORE ROAD
b.On-Site Manager Address
401-737-2000
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3 S
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100114915
Decal Number
B. Facility Description (cont.)
5.
NATIONAL REFRIGERATION
a.Name of General Contractor
WARWICK
c.City/Town
02886
d.Zip Code
AIG
f.Contractor's Worker's Comp.Insurer
6. What is the size of this facility?
3600 WEST SHORE ROAD
b.Address
1401-737-2000
e.Telephone Number(area code and extension)
1WC5312904
g.Policy Number
a.Square Feet
11/4/2010
h.Exp.Date(mmidd/yyyy)
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
ACCUTECH INSULATION &CONT, INC.
a.Name of Transporter
LLUDLOW
c.City/Town
01056
d.Zip Code
2. Transporter of asbestos-containing waste materia
3.
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
144688
f.Zlp Code
100 STATE ST. BLDG 119 PO BOX 376
b.Address
4135835500
e.Telephone Number
I from removal/temporary site to final disposal site:
10 NORTHWOOD DRIVE
b.Address
18602182428
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
' ed i this notification is true and correct
t th b t of h's/he kno ledg d b ref
anf001ap.doc•10/02
FAITH LEMAY
a.Name
ADMIN ASST
c.Position/Title
4135835500
e.Telephone Number
1100 STATE ST BLDG 119
q.Address
77c2-77:-/
ITH LEMAY;
b.Authorized Signature
(10/15/2010
d.Date(mm/dd/ywy)
IACCUTECH INSULATION'
f.Representing
PO BOX 376
LUDLOW
h.City/Town
01056
i.Zip Code
Asbestos Notification Form•Page 3 of 3 MI
1)