109 Asbestos Notification Form 2000 faty b .scription
t Current or prior use of facrlity n
.. Is the faalhy owner-occupied residential with 4 units or less? X Yes ❑ No
3 Caddy Owner'.
JOhv L - e4if 1.49 Mar ke p
t
,,,,
`I A,, Address
11)0 r`I'�'laxnptah mn oto(ae /{(3- 63y-a;
J97,-, .. I,4 rode Telephone
4 Faciliry's Owner's On-Site Manager.
Telephone
5 General Contractor.
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd .
Vane Ac lest ....
Northfield MA . 01360 413 498-0201
oNSTmvn Zip code Telephone
Granite State Ins'. Co . WC /a5-09-42 9Hot
Conrracm rs Workers Comp.Insurer Poky/
6. What is the size of the facility? 3640 (sq ft) a (N of floors)
Exp.pale
9 Asbestos Transportation and Disposal
Transporter of asbestos-containing waste material from site to temporary storage site(if necessary)to final dist
Shearer S Snide Inc . dba/Ace Asbestos 716 Pine Meadow Rd .
Name Adh/fie
Northfield MA 01360 413 498-0201
,.c,owl 2,,7,%Yle Telephone
2. Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site
same as above
Note: Transfer
Dpe Terelxape
Commonwealth of Massachusetts
Asbestos Notification Form — ANF-001
QAsbestos Abatement Description
I. Facility location:
�.au)rtace. sruLncC Address
/09 /ila,ket ,Sheet
Nave
�
IteD17 iif71X AlP
a
e Gel, Igo NAM INennone
,ei
boo 2 Is the facility occupied? - Yes 72 No
i R,1R
layS
3. Asbestos Contractor:
WW1 Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meacoe: b
0/060 *3 (,3V- a�d
bar None Address
Northfield MA . 01360
nen¢
;r no rode rennnone
en C00.00)
ons
AC000006 t� iefrlr/6)
v/ale r amen#t CWlbdl rrre(enlNONLW/
4. On-Site Project Supervisor/Foreman'
Farm Ed Shearer/Tom Shearer AS70245 , AS70066
xnrie
au cenntmmv/
413 (2 95—C
of
5 Project MonOar'.
m
12- Name
6. Asbestos Analytical Lab:
ie
le
Beg on
Boon/
MS
S,,40
FLI�VlconlmEa S 1
wane uG OpCMffranw/
(J3c 3U
7 Project start dateii/Tend date// 9/�specillc work hours(Mon Fri) o a- y :Sat Sun )
O.V.MSedgq✓
1'A GCS? 1.32--
B. What type of project is this? (circle one).
renonno7)
Stations must
comply with the
Solid Waste
Division regular
Irons 310 CMR
18.00
Note:Contractor
must sign this
form!iv DC
notification
purooses
3. Refuse transfer station and owner(i1 applicable)
N/A _.
uyrtoen
4 Final Disposal Site:
Valley Landfill
lolibnNyne
Pleasant Valley Rd .
mows
Irwin
Adores
tetennone
Waste Management/ Logano TrL
thYnerS Marne
PA 15642 724 744-7446
re%oneon.
D
Certification
The undersigned hereby states,under the penalties of perjury,that he/she has read the Commonwealth of Massachuset
tor the Removal.Containment or Encapsulation of Asbestos,453 CMP 6.00 and 310 CMR 7.15.and that the informatio
this notification is true and correct to the best of his/her knowledge and belief.
561"(A! D.3 hearer
Poml Name
C)resident
Vmoronfiee
Armorvel Shrove Odle
Shearer & Snide Inc. dba/ 4 .
Ace Asbestos Removal
716 Pine Meadow Rd . ,
aenresemmp
Northfield , MA. 01360
... /n.rsxle
Itlephnne
Fee exempt(City. rown,district,municipal housing authority, owner-occupied residential of four units or less)1
Sticker*(from front of form). / 3 03
9. Describe the asbestos abatement procedures to be used (circle)_ glove tag urcmswe emn,e,.,,re,�
enbrmn dur�aror. set—up variable air
rmsa
poly work area , '=!':I __. ..
filter respirator , .;..: esto_
10. Is the job being conducted ,a',indoors _'outdoors ?
11. Total amount of each type of Asbestos Containing Materials(ACM)to be handled on pipes or ousts'linear n. 0 or mhei
surfaces(square ft.) y)O to be removed, enclosed or encapsulated
linear/square leer
boiler breaching duel lank sprlace coatings pierma/mbdcore piper ulalia.
corrugated or bye's'paper pipe insulation aO/ msularmg cement
spray-on breprriaing / vows pspayer coatings
cloth wren bona Waist's bard wall bead
oU,er(please describe).
12. Describe the decontamination system's)to be used 3 c ha in her decon unit
shower, tyve'c suits , HEDA vac for clean—up.
13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(d)
Rewet asbestos & pack in labeled double sealed r _
14 For Emergency Asbestos Abatement Operations,the DEP and DLI officials who evaluated the emerge,,.
Mum a DEP Official
idle wa,nwvxan
Nam or Ufb of
QiO d&I f wetroa
ride
Nan/
nce
15. Do prevailing wage rates apply as per M.G.L c. 149, §26, 27,or 27A-F to this project? ET Yes XNo