177 Asbestos Notification Form 2001 Note: Transfer
Facility Description
Current or prior use of facility:
2 Is the facility owner-occupied residential with 4 units or less? p Yes ❑ No
3 Facility Owner:
Lis 4 rE, f EE / 77, Crescent St
Name Address
N � PMti M + 0/060 543 SF6 ,357V
Clry/low„ Ancule Telephone
4 Facility s Owner s On-Site Manager.
�tenowls
Dn urle Teleliaie
5. Genera!Cantractor:
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd .
Name Address
Northfield MA . 01360 413 498-0201
Ciypow ZIP code relephone
Granite State Ins . Co . wc8540584 09/01/01
Contractor's Workers Comp.insurer Polity/
6. What is the size of the facility?3&K7L(so ft) :9. (I of floors)
Exp Dare
13 Asbestos Transportation and Disposal
1. Transporter of asbestos-containing waste material from site to temporary storage site(if necessary)to final disposal site
Shearer & Snide Inc . dba/Ace Asbestos 716 Pine Meadow Rd .
came Annnsa
Northfield MA 01360 413 498-0201
city/Toll Lip rode Telephone
2. Transposer of asbestos-containing waste material from removal/temporary storage site to final disposal site.
Logano Trucking-Waste Mgmt 209 Pickering Street
Name maps,
Portland CT 06480 860-342-0667
Cory/Town Zip axle Ttlelione
IN ST RU CIlO KS
All sections ol this
Ira must be completed
order to comply with
e Department of
nvironmental
roteclion notileation
!quvemen6 ol 310 CMR
15 (lenwnrkiag days
nos nalkkdliw is
anuned of any abatement
role[) and The
lepartm enl of Labor
nd Industries
otitcation requv ements
I453CMR612 (len
Lays oar nab/ration 5
eguired of ANY
basement po)xf yeater
tan three lava or
nude lee)
Submit Cc iginal Form
fommpnweallh of
Aassachucalts
Isbsslos Program
.0.1.120087
last n,MA 02112-
toe/
1. This loan may be
!sod Ior norilpng the
S.Envvalmemal
>rotedlon Agency Region
ol asbestos demolition/
encvMim operations
;ubied to NESRAPS 140
:FR Saipan M}.
Commonwealth of Massachusetts
Asbestos Notification Form — ANF-001
13 Asbestos Abatement Description
1 Facility location:
/scree Frc/t) JCG /77 Crescent 1=
Address
Name
Lily/To
Ala R rvP764) HA 6/060 71/3 5f6- _z 57 .
bct_:ern.ecit_
bp rule Ielephone
WWI is the eabile nation?WOO):amt./.wing, lax awn
2. Is the facility occupied? k Yes E No
3. Asbestos Contractor:
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd .
Nary
Northfield MA .
llWfown
A0000006
IXILtense/
Address
01360
Zipa t
r(-P(1
cImtusJ lyre(imam/vernal)
4. On-Site Project Supervisor/Foreman.
Ed Shearer/Tom Shearer AS70245 , AS7
VLl Cendia&W/
Nall.
5. Project Monhor:
Nan
6. Asbestos Analytical Lab:
1Y16ejlic 4U',/
E V, O6J 1t/fili s4M Ua16 R� / 000 /
Name srmiG OtiC kayo/ O
7. Proleetstad date 666iend date 017/eisPecificwarkhaurs(Mon.-Fri.) ise -VJ(Sat.Sun.) rIV
ii update
a heat
6. What type of project is this? (circle one): ems .y.:.r 'J smsderg
system
413 498-0201
lelegpne
NO RT itAMPTON BOAR OF HEALTH
Stations must
comply with the
Solid Waste
Division regula-
tions 310 CMR
18.00
Note:Contractor
must sign this
form for DU
notification
purposes
3. Refuse transfer station and owner Of applicable)'.
N/A
Mane Adding
ihrytche
4 Final Disposal Site:
Valley Landfill
In-vau Ham
Pleasant Valley Rd .
Address
Irwin
Lprate lehnepne
waste Management/ Logano Truc
Owners Nam
PA 15642 724 744-7446
n■nhnm
D
Certification
The undersigned hereby states.under the penalties of penury,that he/she has read the Commonwealth of Massachusetts R
for the Removal.Containment or Encapsulation of Asbestos,453 CMR 6.00 ana 310 CMR 7.15,and That the iniorrnalion cc
this notification is true and correct to the best of his/her knowledge and belief.
&/ulard Shearer
Pet rime
Positron/Tyre
Au Amin!Srynaure Dale
Shearer & Snide Inc. dba/
Ace Asbestos Removal 413 49
716 Pine Meadow Rd .
Add,en
Renreunnno Telephone
Northfield , MA. 01360
Gb/Tuvoe Ln rule
Fee exempt(City,Town,district municipal housing authority, owner-occupied residential of four units or le
Sticker(front front of form): 75072 /
7>�Y
fro
mnm
92
9. Describe the asbestos abatement procedures to be used (circle): gave nag encasure lul[MIY�J [maw
set—up variable air pressure,
poly work area ,HEPA vac , HEPA
filter respirator, wet asbestos
encazublion
msrusat omr
mmer/erryain)
10. Is the lob being conducted lmdoors D.outdoors? a
11. Total amount of each type of Asbestos Containing Materials(ACM)to he handled on pipes or ducts(linear f.) 90 °rather
surfaces(square ft.) .Sw to be removed,enclosed or encapsulated:
linear/square Ieef
boiler,breaching,dud,tank surface coamnps.. L.5-fp
corrugated or layered pave pipe insulation.... 947 I_
spray-on fireproofing
°toils,woven fabrics._ _...... _.... _�
ober(please describe)
12. Describe the decontamination systems)to be used:
3 chamber de con
shower , tyvekc suits , HEPA vac for clean-up.
thermal solid core pipe insulation
ursulatirg cement
vowel/sprayer coatings
Iraaite board,wall board
unit w/warm water
13. Describe the container¢ation/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(8).
Rewet asbestos & pack in labeled double sealed poly bags
before removal from site .
14. For Emergency Asbestos Abatement Operations,the DEP and DLI officials who evaluated the emergency.
Mane or MP Onkial
Na Dark o Authoaralion Wale"
apt Ulnae (o•
NM CIAJiKYfkn
15. Do prevailing wage rates apply as per M.G.L c. 149, §26.27,or 27A-F to this project? ❑ Yes No
Tine
Wei wr