25 Asbestos Notification Form 2010 Important:
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INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100100429
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?❑Yes 17 No
b.Provide blanket decal number if applicable:
2. Facility Location:
LAZARUS PROPERTY
a Name of Facility
Northampton
c.Ciy/Town
3. Worksite Location.
1.All sections of this
form must he
completed in order
to comply with 4
DEP nol'Iticatbn
requirements of 310 5
CMR 7.15
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR6.12
0
a
BASEMENT
a.Building Nanre/Building Location
MA
d.State
b.Building it
Is the facility occupied? ❑Yes p No
Asbestos Contractor:
Blanket Decal Number
125 HINKLEY ST
ACE ASBESTOS REMOVAL&INSULATION
a.Name
NORTHFIELD
c.Cily/rown
01360
d.Zip Code
AC000006
f.DOS License Number
(THOMAS SHEARER
�h.ready Contact Person
THOMAS R.SHEARER
6' a.Name of On-Site Supenisor/Foreman
7.
8.
RAYMOND BRESNAHAN
a.Name of Protect Mender
ENVIRONMENTAL SAMPLING AND TESTING
a.Name of Asbestos Ana
Lab
9 12/2/2010
a.Protect Start Date(mMddtyyyy)
7-5
b.Street Address
01060
e.Zip Cab
c.Wing
4136283375
f.Telephone Number
d.Floor
0.Room
01 CROSS RD
b.Address
[4134980201
e.Telephone Number
g. Contract Type:
l7
Written Verbal
[SUPERVISOR
i.Contact Person's Title
AS070086
c.Work hours Mon Fri.
10. a.What type of project is this?
❑ Demolition
❑ Repair
rA
Renovation
❑ Other, please specify:
11. a.Check abatement procedures:
❑Glove bag
❑ Enclosure
❑ Cleanup
Full containment
to
❑ Encapsulation
❑ Disposal only
❑Other,specify,
12. Is the job being conducted: • Indoors?
anl001ap.doc•10/02
b.SupeMsa/Foreman DOS Cearfica ion Number
AM900294
b.Project Monitor DOS Certification Number
AA000132
b.Asbestos Analytical Lab DOS Certification Number
2/4/2010
b.E not Dam(mm/ddyyyy)
NA
d.Work tours Sat-Sun.
b.Describe
b.Describe
❑Outdoors?
Asbestos Notation Form•Page 1 of 3