421 Asbestos Notification Form 2010 rtant:
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
[1-00101101
•
1
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'/ 4 Yes ❑No
IUCTIONS
b. Provide blanket decal number if applicable:
Facility Location:
DEPT VETERAN AFFAIRS MEDICAL CTR J
a.Name of Facility
NORTHAMPTON
c.City/Town
3. Worksite Location:
RMS 209&210, CRAWLSP 1 BLDG#2 1
a.Building Name/Building Location b.Building#
sections of this
nust be
eted In order
,pry with 4
Iota:cation
ments of 310
7.15 5
ie Division
:upationai
(DOS)
anon
ements of453
B 12
0
0
0
6
7
8
9
Blanket Decal Number
421 MAIN STREET
MA
d Stale
Is the facility occupied? p Yes ❑No
Asbestos Contractor:
ACCUTECH INSULATION &CONTRACTING 1
a.Name
LUDLOW 1 [01056
c.City/Town d Zip Code
AC000005
1.DOS License Number
PATRICIA O'FLAHERTY i
h.Facility Contact Person
ANTHONY G. ROY SR
a Name of On-Site SuRervisor/Foreman - -
ATC
a.Name of Project Monitor
SCILAB
a.Name of Asbestos AnalRical Lab
2/18/2010 1
a.Project Start Date jmm/dd/yyyy)
7:30-5:00
c.Work hours Mon-Fri.
10. a.What type of project is this?
❑ Demolition S Renovation
❑ Repair iLI Other, please specify:
11. a. Check abatement procedures:
❑ Glove bag
❑ Enclosure
❑ Cleanup
❑ Full containment
1
IT Encapsulation
❑ Disposal only
0 Other,specify:
b.Street Address
01053
e.Zip Cade
4135844040
f Telephone Number
L_
c.Wing d.Floor
e Room
100 STATE STREET
b.Address
[4135835500
e.Telephone Number
g. Contract Type: _]Written ❑Verbal
I.Contact Person's Title
AS071233
b.Supervisor/Foreman DOS Certification Number _
LAA000005
b.Project Monitor DOS Codification Number
1AA000162
b.Asbestos Analytical Lab DOS Certification Number
3/1/2010
b.E nd Date(mml dd/yyyy)
N/A
d.Work hours Sat-Sun.
b.Describe
b Describe
12. Is the job being conducted Indoors? j_ Outdoors?
f001ap-doc•10/02
Asbestos Notification Form-Page 1 of 3
1
N
o 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? Yes❑No
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100101101
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or
encapsulated
500 600
a.Total pipes or ducts(linear f1) b.Total other surfaces(square 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
Lin.X.
Lin.ft.
Sq X d. Insulating cement
Sq X f.Trowel/Sprayer coatings
Lin.X. Sq.X.
h.Transite board,wall board
Lin R S
500
Lin.(1. Sq
j.Other,please specify:
1
Sq.X.
Lin.X. Sq.X.
LX. crSill
Lin.X
600
So.fl
14. Describe the decontamination system(s)to be used:
DEBRIS
Specify
SEAL CRITICALS W/6 MIL POLY ATTACH 3 STAGE DECON UNIT&INSTALL AIR FILT EQUIP
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
LCM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a Name of DEP Official b.Title
c Date(mm/ddlyyyy)of Authorization d. DEP Waiveri
Il
e Name of DOS Official
g.Date(mmlddlyyyy)of Authorization
f. DOS Official Title
I F—
h.DOS Waiver#
o B. Facility Description
0
0
0
1 Current or prior use of facility
2. Is the facility owner-occupied residential with 4 units or less? 1 I Yes No
3.
(VETERANS MEDICAL CENTER
IL 4.
z
US ARMY CORP
footap doe•10/02
a Facility Owner Name
ONCORD 101742
c.City/Town d.Zip Code
NIKKI EMOND _
a.Name of Facility Owner's On-Site Manager
_.. _
d.Zip Code
c.City/Town
696 VIRGINIA ROAD
b.Address
(978) 318-8022
e Telephone Number(area code and extension)
b.On-Site Manager Address
(413)733-6544
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3
J
rransfer
is must
r with the
Vesta
ttions 310
9 000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
Decal Number
B. Facility Description (cont.)
EASTERN GENERAL 1
a Name of General Contractor
SPRINGFIELD J 1109
c.City/Town d Zip Code
;COMMERCE& INDUSTRY
LContractors Worker's Comp. Insurer
6. What is the size of this facility?
52-60 BERKSHIRE AVENUE
b.Address
[(413)733-6544
e.Telephone Number area code and extension)
1
WC5312904 1 11/4/2010
q.Policy Number h.Exp.Date(mm/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(
ACCUTECH INSULATION&CONTRACTING
a.Name of Transporter
LUDLOW
c.City/Town
01056
d.Zip Code
necessary):
100 STATE STREET
b.Address
135835500
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
X173 PICKERING STREET
b.Address
8603421022
Telephone Number
3.
BRED TECHNOLOGIES
a.Name of Transporter
;PORTLAND 1 106480
d.Zip Code
c Cy/Town
4
a.Refuse Transfer Station and Owner r
i
b.Address
L
c.City/Town d.ZJp Code
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
[OH
e.State
cn
o D. Certification
e.Telephone Number
1
[44688 1
f.Zip Code
b.Final Disposal Site Location Owner's Name
1WAYNESBURG
d.City/Town
g.Telephone Number
The undersigned hereby states,under the
o p If fp jry,thth / h h dth
o Commonwealth of Massachusetts regulations
f th R I C 1 . t
• Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15,and that the information
t d tH ff. C t d t
o t th b t f h' /h k I dg nd b li f
o
IL
Z
1001apdoc•10/02
;JEAN A KUMIEGA _J
a.Name
(ADMIN ASSISTANT 1
c.Position/Title
14135835500
e.Telephone Number
Je i r(KSlmi gY/r iA'/1„,,
bf Authorized Signature
2/3/2010
d Date(mm/dd/wyy)
ACCUTECH
f.Reoresentin
100 STATE STREET
g.Address
,LUDLOW
h.City/Town
11056
Zip Code
Asbestos Notification Form•Page 3 of 3