11 Asbestos Notification Form 2012 Environmental, Inc.
29 Bane Road
Templeton, MA o1468
May 30,2012
Attn: Health Agent
Board of health
212 Main Street
Northampton, MA o'o6o
Re: Asbestos Abatement
Residential
u Orchard St.
Northampton,MA olobo
Dear Sir or Madam:
Tel: 978-874-1871
Fax: 978-874-1027
www.ae-enviromnental.com
Please be advised that A&F Environmental, Inc.will be performing,an Asbestos
Abatement project at the above referenced location on the scheduled dates:
Start Date: 06/12/2012
End Date: 06/12/2012
All applicable State and Federal Agencies have been notified.
If you should need any further information,please contact me.
Sincerely, p�
Michael Lauziere
Director of Operations
Commonwealth of Massachusetts
out
key
is
rn
/NS
s of this
order
4. Is the facility occupied? pl Yes
Jon
of 310
5. Asbestos Contractor:
Asbestos Notification Form ANF-001
100149344
Decal Number
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? 17 Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
(RESIDENCE
a Name of Facility
NORTHAMPTON
c. City/Town
3. Worksite Location:
[BASEMENT —I
a Building Name/Building Location
ion
of 453
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A&E ENVIRONMENTAL
MA
d State
1
b.Building#
❑No
Blanket Decal Number
111 ORCHARD STREET
b.Street Address
101060 J 4135840977
e Zip Code f.Telephone Number
a Name
WESTMINSTER
C.City/Town
IAC000326
I 101473
d Zip Code
f.DOS License Number
(EDWARD DUNNY
h.Facility Contact Person
/MICHAEL LAUZIERE
6. a.Name of On-Site Supers sor/Foreman
7 (NORTHEAST ENVIRONMENTAL
a Name of Project Monitor
8 (NORTHEAST ENVIRONMENTAL
a.Name of Asbestos Analytical Lab
16/12/2012
9' a.Project Start Data tmm/rid/yyy)
8AM-PM
c Work hours Mon-Eri.
10. a. What type of project is this?
❑ Demolition ] Renovation
❑ Repair
❑Other, please specify:
11. a. Check abatement procedures:
'u Glove bag
❑Enclosure
El Cleanup
Z Full containment
12. Is the job being conducted.
Li Encapsulation
❑ Disposal only
7 Other, specify:
c Wing
r �
d Floor
r170 STATE ROAD, E2
b Address
788741871
e.Room
1
I
e.Telephone Number
g. Contract Type: ❑Written ❑Verbal
rWNER —
i.Contact Person's Title
AS001702
b.Supervisor/Foreman DOS Certification Number
IAM031319 1
b.Project Monitor DOS Certification Number
IAA000153 ll
b.Asbestos Analytical Lab DOS Certification Number
6/1212012
b End Data(mm/ddlyyyy)
d Work hours Sat-Sun.
1
b.Describe
b.Describe
Z. Indoors? ❑Outdoors?
p.doc•10/02 Asbestos Notification Form•Page 1 of 3■
1. Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100149344
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated.
120 1 '120
aTFpipes or dii Fiinear ft) b. Total other sudaces square
r
c. Boiler, breaching,duct,tank i 1 120 J } !.
surface coatings Lin.ft. Sq.ft. d. Insulating cement Lin.R. Sq.if
e. Corrugated or layered paper '20
pipe insulation Lin.ft. Sq.ft.
f TrowellSprayer coatings
Lin. ft. Sq ft
g.Spray-on fireproofing Lin.ft. ISq.fl. -I h Transite board,wall board (Lin ft 'Sq fi.
1 l r 1 1
i. Cloths,woven fabrics t— i 1— ).Other, please specify:
_ .._ 4 R_.-__._ Lin.ft. Sq.tt.
Lin.fl S
k Thermal,solid core pipe
insulation
r 1 F
Lin.R. Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used
(WORKERS ENTER AND EXIT VIA CHANGE ROOM WITH PROPER RESPIRATOR.
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
[ACM WET DOUBLE 6MIL POLY LABELED BAGS, SEALED LOCKABLE CONTAINER.
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
j
Li.Warne°M.-EP Official b.Title
L 1 J
c. Date(mm/dd/yyyy)of Authorization d.DEP Waiver#
e.Name of DOS Official `f-DDS Official T10e
i _1 L
g.Date(mmlddlyyyy)of Authorization h.DOS Waiver#
-N
Mi
so 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? I,_;Yes [L No
s
B. Facility Description
EN
co 1. Current or prior use of facility: [RESIDENCE
To
M 2. Is the facility owner-occupied residential with 4 units or less? (Z Yes ❑No
e- 3 EDWARD DUNNY I 111 ORCHARD STREET
a.Facility Owner Name b.Address
e-° (NORTHAMPTON 71 101060 j 1413-564-0977
_° c.City/Town d.Zip Code e.Telephone Number(area code and extension)
�a N/A
r. 4. a.Name of Facility Owners On-Site Manager - b.On-Site Manager Address
.Z i
Fa c.City/Town d.Zip Code 'e.Telephone Number(area code and extension)
idoc•10/02 Asbestos Notification Form•Page 2 of 3.
Commonwealth of Massachusetts
ar
he
310
em
14°
Asbestos Notification Form ANF-001
100149344
Decal Number
B. Facility Description (cont.)
A&E ENVIRONMENTAL, INC. JI
5' a.Name of General Contractor
WESTMINSTER 1 01473 1
c City/Town d.Zip Code
AIM MUTUAL
f.Contractors Workers Comp. Insurer
6. What is the size of this facility?
170 STAE ROAD EAST 2
b.Address
1978474.1871 7
e.Telephone Number area code and extension)
117012381012012 -_J 13/1/2013
q,Policy Number h.Exp. Date(mm/dNVyyy)
C i
•a.Square Feet b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
LA&E ENVIRONMENTAL, INC.
a. Name of Transporter
WESTMINSTER A 101473
c. City/Town d Zip Code
1170 STATE ROAD EAST 2 J
b Address
9788741871
e.Telephone Number
1
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
3.
LIOB ROLLOFF,INC.
a. Name of Transporter
CHELSEA
c.City/Town
a Refuse Transfer Station and Owner
J
102150 1
d.Zip Code
P.O. BOX 6037
b Address
j6173871495
e.Telephone Number
L
b Address
c. Chy/Town d.Zip Code
4. (TURNKEY LANDFILL(WASTE MGT NH) 1
a.Final Disposal Site Location Name
7 ROCHESTER NECK ROAD
e.Telephone Number
b.Final Disposal Site Location Owners Name
[ROCHESTER
c. Final Disposal Site Address d.City/Town
OH L )08339 1 1111.
e.State f Zip Code
I
g.Telephone Number
• D. Certification
o The undersigned hereby states,under the
iO penalties of perjury,that he/she has read the
G° 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.
an_
-z
.<
neoc•10/02
DIANE HUBBARD
a.Name
[CFO/TREASURER 1
c.Position/Title
9788741871
e.Telephone Number
1170 STATE ROAD EAST 2
g.Address
(WESTMINSTER
h.City/Town
DIANE HUBBARD 1
b.Authorized Signature
(5/30/2012
d Date(mMtld/vyvy)
A&E ENVIRONMENTAL,
f.Representing
1473
j
1
i Zip Code
Asbestos Notification Form•Page 3 of 3M