53 Asbestos Notification Form 2009 HC";.::
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100088736
Decal Number
A. Asbestos Abatement Description
1. a.Is this facility fee exempt-city,town, district, municipal housing authority,owner-occupied
residence of four units or less?❑Yes 14 No
b.Provide blanket decal number if applicable:
2. Facility Location: 1
'CLARK AVENUE CONDOMINIUM ASSOC.
IONS
me of
be
in order
with 4
ration
Its of 310 5
vision
)S)
nts of 453
a.Name of Facility
NORTHAMPTON
c.Cityfrown
3. Worksite Location:
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0
6.
BASEMENT
MA
d State
a.Building Name/Building Location b.Building#
Is the facility occupied? LA Yes ❑No
Asbestos Contractor:
a.Name
LUDLOW
c.Oitynown
AC000005 _
f D S License Number
GREG NEFFINGER
h.Fadli Contact Person
ANTHONY G.ROY SR
ervisor/Foreman
101056
d.Zip Code
Blanket Decal Number
101060
e.Zip Code
c.Wing
1(413)734-5751
f.Telephone Number
d.Floor
l-
e.Room
1100 STATE STREET
b.Address
14135835500
e.Telephone Number
Name of On-Site S
NIA
7. Name ajlaae of Prdect Monitor
NIA
a.Name of Asbestos Anal
06/02/2009
a.Pro act Start Da
8:00.5:00
c.Work hours Mon-Fn.
0 10. a.What type of project is this?
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ea
g. Contract Type: Fl Written ❑Verbal
i.Contact Persons Title
AS071233
b.Supervisor/Foreman DOS Certification Number
cal Lab
❑ Demolition 0 Renovation
❑ Repair ❑Other, please specify:
11. a. Check abatement procedures:
❑Encapsulation
❑ Disposal only
[] Other, specify:
❑Glove bag
❑ Enclosure
❑ Cleanup
❑ Full containment
12. Is the job being conducted:
fOtap.doc•10102
b.Project Monitor DOS Certification Number
b.Asbestos Anal that Lab DOS Cedifcatlon Number
106)02/2009
b.End Date mmldd
NIA
d.Work h
REMEDIAL CLEAN
b.Describe
Indoors? [1 Outdoors?
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Asbestos Notification Form-Page I of 3
1
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100088736
Decal Number
•
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or
encapsulated:
a.Total pipes or ducts(linear ft)
c.Boiler.breaching,duct,tank Lin.ft
surface coatings
e.Corrugated or layered paper Lln.ft.
pipe insulation
Lin ft. i
1 I
rLin. t.
J
Lin.ft.
1100
b.Total other surfaces(square ft)
g.Spray-on fireproofing
L Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
14. Describe the decontamination system(s)to be used:
1SEAL OFF THE AREA USING BARRIER TAPE.WET DOWN THE ACM WI AMENDED WATER 8 1
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
ACM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED 6.14(2) (g):
I
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
a.Name of DEP Official b Title
1 1 -DEP Waiver#
c.Date(mm/ddtyyyy)of Authorization
e.Name of DOS Official
g.Date(mm/dd/yyyY)of Authorization h.005 Waiver k
26, 27 or 27A–F apply to this project? ❑Yes 7 No
o 17. Do prevailing wage rates as per M.G.L. c. 149, §
B. Facility Description
CONDOMINIUMS
• 1. Current or prior use of facility —
0
2 Is the facility owner-occupied residential with 4 units or less? ❑Yes (7 No
173 MAIN STREET
b.Address
`01002 1 1413-734-5751 b (area code and extension)e.
Telephone Number
Sq.ft.
Sq.ft.
Sq.ft
d.Insulating cement
f.Trowel/Sprayer coatings
h.Transite board,wall board
S fl 1 Other,please specify.
(AM— REM CLN SOIL
Sq.fl. I.Specify
Lin.ft
Sq.ft
Lin.ft. Sq.fl Lin.ft.
n.ft.
100
Sq ft.
1 If DOS Official Title
3 'EAGLE CREST PROPERTY MANAGEMENT 1
a.Facility Owner Name
o [AMHERST
o a Ci /Town
GREG NEFFINGER
LL 4' a Name of Facility Owner's On-Site Manager
iQ L.City/Town d Zip Code
d Zip Code
1E001ap doc•10/02
(a e 1
lb.On-Site Manager Address
413-734-5751
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa ea a 2
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
00088736
Decal Number
B. Facility Description (cont.)
5' a.Name of General Contractor
a City/Town
d.Zip Code
COMMERCE&INDUSTRY
f Contractors Workers Comp.Insurer
6. What is the size of this facility?
b Address
e.Telephone Number area cod and extension)
WC5312904
g.Policy Number
a.Square Feet
11/04/2009
h.Exp.Date(mm/dd/yyyy)
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
ACCUTECH INSULATION &CONTRACTING
a.Name of Transporter
LUDLOW
c.City/Town
01056
100 STATE STREET
b Address
(413)583-5500
d Zip Code e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
3
4
RED TECHNOLOGIES
a.Name of Transporter
PORTLAND
c.City/Town
06480
d Zip ode
173 PICKERING STREET
b.Address
(860)342-1022
e Telephone Number
a.Refuse Transfer Station and Owner
c.City/Town
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
9000 MINERVA ROAD
c Anal Disposal Site Address
dZi Co
J
7
OH
e State
°
44688
f.Zip Code
b.Address
e.Telephone Number
b.Final Disposal Site Location Owners Name
WAYNESBURG
d Cay/Town
g.Telephone Number
D. Certification
The undersigned hereby states,under the
° penalties of perjury,that he/she has read the
0 Commonwealth of Massachusetts regulations
for the Removal, Containment or
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15,and that the information
contained in this notification is true and correct
to the best of his/her knowledge and belief.
O
LL
A001ap.doc•10/02
HEATHER R.CREPEAU
a. Name
OFFICE MANAGER
c.Position/ritle
(413)583-5500
e.Telephone Number
05/20/2009
d.Date(mm/dd/ww
ACCUTECH
L Representing
100 STATE STREET
q.Address
LUDLOW
h.City/Town
01056
i.Zip Code
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Asbestos Notification Form•Page 3 of 3