92 Asbestos Notification Form 2000 Note_ T ransler
Facty Description
' Current or prior use of facility:
R£SND EA3 CE
s the facilrty owner-occupied residential w h d colts or less.] $( Yes ^ No
:acdity Owner.
Jean Z;mmer 9a �/avnar�( Rd
aa�, 4ddess J
/Uodfhamphn Ma 01060 'I%3 see/ 41762
Ombe
s Owners On-Site Manager.
N/A
Telephone
5 General Contractor.
6oearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd .
Name A6dress
'orthfield MA . 01360 413 498-0201
Du woe Telephone
Granite State Ins. Co . NO /3507-62 9/it"
Conracrc S Workers Comp Insurer nap.Dale
.: What is the size of the faciliryl,43456 (sq fll al. (#of floors)
j 'ysir stos Transportation and Disposal
#f r�
Trarisborter of asbestos-containing waste material from site to temporary storage site (if necessary)to final disposal site.
( ydaret & Snide Inc. dba/-Ace Asbestos 716 Pine Meadow Pd .
N.pne Adores
,orthfield MA C1360 413 498-020]
Toophune
2 Transporter of asbestos-containing waste material from removal/temporary storage site to final disposai site
same as above
Grypoxs' Telephone
IN SIRU CTIO NS
:. 5FIIens...
'orb Ines r,COmpreFC
'erne l la Lobe,.we
:t Oepinmenl or
Erm ronmenleI
Peolealion n;Jlea;pn
[mallMIR A-3 ten l.
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mrauon le
Commonwealth of Massachusetts
Asbestos Notification Form — ANF•001
QAsbestos Abatement Description
1 Facility location. q -�
immt, reshdcace, v. A'ic nnand %- cd
N&oe wean J
oRTN 1t P7D/ke1 M i OiaGa S2 Y- 'f769
2. Is the Iacilfy occupied? r Yes _ No
3 Asbestos Contractor.
cC Mani acaIemene Shearer & Snide Inc dha/Ace Asbestos 716 Pine c r - : `
,Doe.., anC Me
Ind of Labor
I 473 44s
me mbmv ie1 Northfield MA . 01360
6463 MR l 612 lenls Ira mace Iemeeone
says eol2 (ten GrjOow
'equ &CI A,hcallo'�s c�nilrl,
repw,eeni vo: AIbeseI 6
aca:emerl9mPl'q'®le, IXltlrzns/ camirl l/Ie lwnllanA'erLBl/
r^an Iwx Irma o/
,,,y M, 4. On-Site Project Supervisor/Fc reran.
w.. Ed Shea rer/lore Sh ea re: AS70246 , AS7r
Dmnerarme/
Commonwulth of
Massachusetts
Asbestos Pre gram
P.D.B.1200E7
Baste,MA 02112-
Don
-Sea 10 nor l yng 0e
S.:Ovacorneal
'S.lan kxncy nesaa
v:esoeslos dan oiciaN
er
�evanon oxrmmns
seGlttY:a h%SMRP3;4G
_,n 3eo¢sr.IA;
Name
5. Project Monitor.
Let LervL maw:/
6. Asbestos Analyaca:Lab
fN✓j,eipA)/ fVTiL Syry 'tiiC6 8 as7/ AAQ001
stecallml/
Name p C Jae
/. Project start date 4 /?�Xeno dale 6I 43'specific Apt flours tMon.-Fri) 6a." / Sa: Sun '
B. What type of project is this", (circle one)'.
renal ((mommy
comely with the
Solid Waste
J".':SIo^ eepll!a'
aas: fe,C:V
Note-Contract:'
'nustS.QC t.S
o u�
'�ch1'ca imn
OUtOOSes
3 Refuse Iransf er station and owner (if applicable).
N/A
4 Final Disposal Slte
Sauey Landfill ',Caste Management/ Loaano
owners name
D
Pleasant Valley Rd .
Address
=rwin PA
15642
724 794—7 446
Certification
The undersigned hereby states,under the penalties of perjury.that ne/she has read the Commonwealth of Massac
'or the Removal.Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the into!
this notification is true and correct to the best of his/her knowledge and belefef.
ECIALla D Shearer
4u. fl?N banAWe
Shearer & Snide Inc . dba/ 4
Ace Asbestos Removal
c7astDE4Jt
;Are die Mme
716 Pine Meadow Rd .
Reprzunnnp
Northfield , MA . 013
nr rote
!e @Ohone
Fee exempt(City,Town,district,municipal housing authority owner-occupied residential of tour units or I
�
Sticker t (from front of form)'. 739 '7 46
Describe the asbestos abatement procedures to be used (circle)'. gore bag enclosure x[mlm
mrmrvlarror� - set—up variable air
poly work area
filter respiratur , ..�
10. Is the job being conducted $ indoors =outocors ?
Total amount of eacn type of Ascestos donta,nyng Maieriais(ACM)to be handled on pipes w a.:tr /60
surfaces (square ft •ii t10 to be removal, enclosed or encapsulateo
boiler.OlPacing,dua land sonace:bald, anal SOLd N/eGNP�2J�dl0l. __ _
corlugaledor layered paper pipe insulaalmc / : meualing semen%..
spray-on Poeproofng Powealspraall coanrrgs
cloths,
(l ase eSaib uararre board.yell Oband
oNn(please Oescride).
12. Describe the decontamination systemis)to be used a sham her dC Co n
shower , tyve'.<- suits , REPA vac for clean—up.
13. Describe the containerization/disposal metnods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g;
Rewet asbestos & pace in labeled double sealed poll'. .. .
before removal from site .
14. For Emergency Asbestos Abatement 0pera't:ons, the DEP and DL I officials who evaluated the emerge:
CarneaDEPApal
wle or.w;rorvnari
Mire oral antral
pale W konwrunlnci noon
15- Do prevailing wage rates apply as per M.G._ c 149, § 26, 27,or 27A- F to this project? = Yes �`',c