78 Asbestos Notification Form 2001 Note: band./
a
Facility I/ascription
1. Current or prior use of facility. -
R£sID EA)C�
2. Is the facility owner-occupied residential with 4 units or less' Yes 0 No
3 Facility Owner:
HPazi)a ji4e niE2- 78 SojJt NAHL) Sf
Name
Actress
FLOREJC Er fi1A 0.1060 1113 - Sr{-
orynon,
No oak Telephone
4 Facility's Owners On-Site Manager-
0/A
Name
reerkone
5 General Contractor:
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd .
Name
Address
Northfield MA . 01360 413 498-020
city/raw
Lk code
elephMe
Granite State Ins . Co . v/08540584 09/01/01
Contractor's Workers comp.Insurer PokKy/ fxo.Date
6 What is the size of the facility? 3SX6C(ag f)- (I of floors)
Asbestos Transportation and Disposal
I. Transporter of asbestos-containing waste material from site to temporary storage site(if necessary)to final dis,
Shearer & Snide Inc. dba/Ace Asbestos 716 Pine Meadow Rd .
Name AOdrest _ _...
Northfield MA 01360 413. 498-0201
crnelpar,
tm wm mom.
2. Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site.
Logano Trucking-Waste Mgmt 209 Pickering Street
■ame
Admen
Portland CT 06480 860-342-0667
Commonwealth of Massachusetts
Asbestos Notification Form — ANF•001
Asbestos Abatement Description
Facility location.
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Name
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Peale$
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y Region
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Yea IS do eclune lco'rom eundmy lam I.wog.$1001.MOM
2. Is the facility occupied? 'y1 Yes ^. No
3. Asbestos Contractor:
Shearer & Snide Inc dba/Ace
Nair
Northfield
MA .
annown
A0000006
IXltica=f
4. On-She Project Supervisor/Foreman:
Ed Shearer/Tom Shearer
Nal*
5. Project Monitor.
0 -h mc�:n Sr
Address
OI_Q60
211)axle
Asbestos 71
Address
01360
Alp owe
L ( \He-n
r nlo]Tyt (wnhn4etta)
Nene
6. Asbestos Analytical Lab:
(glom e' SAM Fume
Name T:Sj :V 6- a$cervr4 t /
�(
_)g Q't o ISal.Sun.) o
C Project start date?/?/0 end date iu l.5/O�specific work hours(Mon:Frl update
omen(expmnr h e a t
system
») ( 2001 t
LLe n66. y
NOATitAPAPFONBOARD OF HEALTH
me ea
413 498-0201
Telephone
AS70245 , AS70066
OLI CeNJiobwl/
Cll CeInp4M/
,.�.....,.,.,a nrnl.rt k this? (circle one): demoulaln
repro
reaYYan
Stations must
oomph,with the
Solid Waste
Division regula-
tions 310 CMR
1800
Note:Contractor
must sign this
form for DU
notdica(ion
ourposes
3. Refuse transfer station and owner Of applicable):
N/A
Name Address
cnypown his rule rerereione
4 Final Disposal Site:
Valley Landfill Waste Management/ Logano T
tPfl GWttrz Nane
Pleasant Valley Rd .
neere.,
Irwin PA 15642 724 744-7446
..iemr0.
D
Certification
The undersigned hereby states, under the penalties at perjury.that heiche has read the Commonwealth of Massachus
for the Removal.Containment or Encapsulation of Asbestos,453 CMR 600 and 310 CMR 7.15,and that the informal
this notification is true and correct to the best of his/her knowledge and belief.
Wtk?urc( D Shearer
Pro/Name
4/3 o/o
Au .- of slunSure Dare
I , Shearer & Snide Inc. dba/
sirs J. + Ace Asbestos Removal
vailwn/Irne
716 Pine Meadow Rd .
Arure„
413
aearessni'no Telephone
Northfield , MA. 01360
Ciry/lown In:rule
Fee exempt(City,Town,district,municipal housing authority, owner-occupied residential of four units or less) '
Sticker J(from front of form): ( J 0 ( e,c'7
9. Describe the asbestos abatement procedures to be used (circle): gore ny emlosure lull can Warm aea ip
set—up varia e air pressure,
encaosmxron disposal , omerfoomnl poly work area , HEPA vac , HEPA
filter reepirator , wet asbestos
10. Is the job being conducted A indoors di outdoors?
—I 1t Total amount of each type of Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear ft) ;25 or ether
surfaces(square tl.) 36 to be removed, enclosed or encapsulated:
linear/square feel
boiler,breaching.duct lank surface coawgs.. /-310 %hernial solid Core pipe insulation
corrugated or layered paper pipe insulation. ram / insulating prawn __J-
spray-on fireproofing ____./____ Vowel/sprayer 003111795
cloths,worm fabric.. _2_ uansite board.wall board
__l-
ather(please desuibe)
12. Describe the decontamination system(s)to be used: 3 chamber deco❑ unit w/warm water
shower , tyVe! • suits , HEPA vac for clean—up.
13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g).
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:
Mare da/OakSl
mu of Authonianon
Name rcrurcm
Wile awnurvalkn
me
Wawa
Tare
15. Do prevailing wage rates apply as per M.G.L.c. 149,§26,27,or 27A F to this project? G Yes
0