52 Asbestos Notification Form 2001 Facility Description
Current or prior use of facility: -
RES/DECCE
2 Is the facility owner-occupied restdeni:ai witr d units or less? XYes = No
5 rapidity Owner:
?iobert Zussman 5a drejev1t nit.
Name Addm¢
/( l /Prl,u MA 0/060 -585-8775-
:erenh lee
Clarano
d. Facility s Owner s On-Site Manager.
I/A
rrlenhmrz
5. General Contractor'.
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd .
Name Address
Northfield 01360 413 498-0201
iy icim lm cage telephone
Granite State Ins . Co . A'CR540584 09/01 /01
Conrncm s Workers Comp.Insurer Cohry/ &p dale
6. What is the size of the facility?c 0(sq N) O2 (S of floors)
Asbestos Transportation and Disposal
t. 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 .
We Address
Northfield MA 01360 413 498-0201
ory/roun / . .e re,nmw:e
2 Transporter of asbestos-containing waste material from removal/temporary storage sue to final disposal site
Logano Trucking—Waste Mgmt 209 Pickering Street
Portland CT 06480 860-392-0667
r wwm
IM ST RUCTIOPO
All SeCI1o1501 m is
rm must ce completes
order b comply with
e Department of
ivlronmenl al
rotes lion notification
ewremen¢oi310 CMA
15 lien worklnp days
'or nofilralion is
quay el any abatement
ole.0:arc the
ep arlmenr al Labor
re Inemtrin
!bl canon recce enenta
453 CMR 6 t2 (len
n Pilot ndianm Is
;weed el ANY
a(emenl payee,'peeeler
W lure'treat or
care feel).
3110:0 Of Ipmal F oem
Immo wealth of
asachuatts
bastes Program
0.8.120067
noon.MA 02112-
67
Troy iorm.may oe
ce lot notbpn;Lie
EnWIXlmenlal
aration Agency Reim
asbestos 001101111011/
Ovation operations
net to NEShAPS 140
Subpart 111
Commonwealth of Massachusetts
Asbestos Notification Form — ANF-001
Asbestos Abatement Description
1 Fealty location.
Zvssmc+n residence
None
I'ha mfg tar? MA
LL{3erne r\t
CIry
5a Crescent S7-
AJwess
ake E775
iobo _
Fr! MNOWN
1,01 FEB 2 I 200 IS
NM IMAM BOARD OF HEALTH
716 Pine
Wily in Pie IwrhOelm'icn?WJdirp ram./.xmp,Pair.room
2. Is the facilely occupied? X Yes = No
3. Asbestos Contractor:
Shearer & Snide Inc dba/Ace Asbestos
Name
Northfield MA .
Ciry/ro+n
AC000006
IXI(/tense/
Aooress
01360
hp code
W ft nein
cmGL rpe lbineMWVbL)
473 498-0201
Telephone
4 On-Site Project Supervisor/Foreman.
Ed Shearer/Tom Shearer AS70245, A570066
Name DLICMi/K4wr/
5. Project Mamba(
Name
6. Asbestos Analytical Lab /� y� 2
Nne VV1reTIJt „7 �/+f�E 371 F- A coo l3 2—
Wine 5-TI KW' IXICeN6eaew✓ ,���
zz
7_ Project start date 3/5/0/end date 3/9/6)//specific work hours(Mon.-Fri.) /�oo-Tl_-yy'(Sat.Sun ) rate
update
8. What type of project is this? (circle one)'. demohhon � - 'can
al[Macedw✓
rtPal emrnlm 11 omen?eeponN
Note: rranster
Stations must
comply with the
Solid Waste
Division regula-
tions 310 CMR
:8.00
Note:Contractor
must sign this
form for DU
notification
ourposes
3 Refuse transfer station and owner Of applicable).
N/A
Name
orynnx,.
4 Final Disposal Site.
Valley Landfill
(IXlpOf N>M
Pleasant Valley Rd .
Address
do ro-te terennnne
Waste Management/ Logano Truckinc
Owners Name
seeress
Irwin - PA 15642 724 744-7446
fccnr .N2 c-. •nhnr.
D
Certification
The undersigned hereby slates.under the penalties of perjury,that he/she has read the Commonwealth of Massachusetts Regulatio
for the Removal.Containment or Encapsulation of Asbestos. 453 CMR 5.00 and 310 CMR 7.15, and that the information contained
this notification is true and correct to the best of his/her knowledge and belief.
44}a/c( ,Pi5h& Ker C ra
r
�cvt� .2// 70/
Anmmvro5tun_
Shearer 6 Snide Inc . dba/
25 rC1�� Ace Asbestos Removal 413 49£3-02
PueroMilie Rearesemmy TAeohone
716 Pine Meadow Rd.
Andress
Northfield , MA. 01360
/r rate
Fee exempt(City.Town,district, municipal
ou
niccii[pal housing authority,owner-occupied residential of four units or less) 14 yes C n
Sticker I (from front of form) / 1 g l 3
airy!gun .
oaaJan
tiwO
Inrwwdw�
sa Lie
Rev 692.
9. Describe the asbestos abatement procedures to be used (circle)_ glare rag exuswe Cur win rule ) getout
set–up variable air pressure ,
emwsurarm oswsaiw, omerlerynnl poly work area , HEPA vec , HEPA
filter respirator , weo asbestos
10. Is the lob being conducted `gtindoors ❑outdoors ?
11. Total amount of each type al Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear fl.) V8v waher
surfaces (square ft.) to be removed. enclosed or encapsulated.
linear/square feet
boiler.breactmg,duce lank surface coatings ITermal solid core pipe vsularion...
corrugated or layered paper pipe msularon TO rr insulaIng cement
spray-on fireproofing.. _/ Uweirsprayer coatings
cIolrts.wown labrics.. uamrle board wall board
obier(please describe). -�
12. Describe the decontamination system(s)to be used. 3 chamber decon unit w/),4 arn: ua cer
shower , tyve'.c- 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 bats
before removal from site .
14. For Emergency Asbestos Abatement operations,the DEP and DL I officials who evaluated the emergency.
Nam d DEP Omkal
This omumorwaiman
marred al airs'
TOP
res
Nu er/
15. Do prevailing wage rates apply as per M.G.L c. 149, §26, 27,or 27A-F to this project? ❑ Yes ‘)(No