811 Asbestos Notification Form 2009 E�
Important
When fling out
forms on the
computer,use
only the tab key
to move your
cursor do not
use the return
key.
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certity your
notification.
Submit date
changes.
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
811811 NORTH KING STREET
2.Street Ad dress
NORTHAMPTON
3.City
4135820523
6.Telephone Numbe
B. Project Cancelled
Il
Check here if this project is/was cancelled.
C. Project Dates
02/09/2009
1.On•mai Start Date mm/d
100083828
Decal Number
3.Latest Revised Start Date(mm/dd/
D. Revised Project Dates
02/05/2009
1.Revised Start Date(mm/dd/rvwl
E. Other Project Revisions
F. Revision History
MA
4State
02/20/2009
2.Orio nal E d Dale lmmldtlNwv
5.Zip5.Zip Code
4.Latest Revised End Date(mm/dd
2.Revised End Date Date(mm/ddlyyyy)
anfo6pdm doc•rev.2/5/04
S
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
1100083828
Decal Number
G. Certification
The undersigned hereby states, under the penalties of perjury,that he/she has read the 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.CMR
Authorized J
102/03/2009
3. Date(mrnlddfvyyy)
1(413)583-5500
5. Telephone
(HEATHER R.CREPEAU
1. Name
OFFICE MANAGER
2. Position/Title
IACCUTECH INSULATION 8 CONTRACTING �
4. Representing
1100 STATE STREET
6. Address
LUDLOW
7. City/Town
anfo6pdm.doc•rev.2/5/04
101056
8. Zip Code
1
Important:
When filling out
forms on the
computer.use
only the tab key
to move your
cursor-do not
use the return
key.
stC
cal
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certiy your
notification.
Submit date
changes.
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
1100083766
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Fealty
1811 NORTH KING STREET
2.Street Address
NORTHAMPTON
3.City
14135820523
6.Telephone Number
MA
4.State
5 Zip Code
B. Project Cancelled
fl Check here if this project is/was cancelled.
C. Project Dates
02/09/2009
1.Original Start Date(mnVddlyyyy)
02/20/2009
2.Original End Date(mr&ddlnvv)
3.Latest Revised Start Date(mm/ddlyyyy)
4.Latest Revised End Date(mmlddlyyyy)
D. Revised Project Dates
02/05/2009
1.Revised Start Date(mm/dd/yyyy)
1
2.Revised End Date Date(mmlddlyyyy)
E. Other Project Revisions
F. Revision History
anfO6pdm doc•rev.215/04
D
NORTHAMPTON O4 FDAD R tt[AITH
FEB - 4 KO
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF•OO1 and AQ 06
100083766
Decal Number
G. Certification
The undersigned hereby states,under the penalties of perjury,that he/she has read the 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.
HEATHER R.CREPEAU
1. Name
(OFFICE MANAGER
2. Position/Title
ACCUTECH INSULATION 8 CONTRACTING
4. Representing
uth0dzed Sionatu
02/03/2009
3 Date(mm/dd/ww)
(413)583-5500
5. Telephone
00 STATE STREET
6. Address
LUDLOW
7. City/Town
ant06pdrn.doc•rev.2/5/04
01056
6 Zip Code
II
1••••
■•••
ACCUTECH INSULATION &CONTRACTING Ih
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
chl
INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-007
•
100083828
Decal Number
A. Asbestos Abatement Description
1.
2.
a.Is this facility fee exempt-city, town, district, municipal housing authority,owner-occupied
residence of four units or less? •Yes ❑No
b. Provide blanket decal number if applicable:
Facility Location:
MASSACHUSETTS HIGHWAY DEPARTMENT'
a.Name of Fadlity
NORTHAMPTON
c.City/Town
3. Worksite Location:
1.All sections of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR 7.15 5.
and the Division
of Occupational
Safely(DOS)
notification
requirements of 453
CMR 6.12
6
7
8
O 9
0
STORE HOUSE/KEEPER
a.Budding Name/Building Location
Is the facility occupied?
Asbestos Contractor:
AMA
d State
b.Building E
Yes F-I No
a.Name
LUDLOW
c.City/Town
01056
d.Zip Code
AC000005
C DOS License Number
KRISTEN WELLS
h.Facility Contact Person
BRANDON E. BESAW
a.Name of On-Site Supervisor/Foreman
URS
Blanket Decal Number
X811 NORTH KING STREET
b.Street Address
10106C j 1(413)582-0523
e.Zip Code f Telephone Number
BASEMENT
c.Wing d.Floor
e.Room
100 STATE STREET
1
b Addres
4135835500
e.Telephone Number
g.Contract Type: GI Written ❑Verbal
a.Name of Project Monitor
URS
a.Name of Asbestos Analytical Lab
02/09/2009
ect Start Date mmld
:00-5:00
c.Work hours Mon-Fri.
I.Contact Person's Title
AS070407
b.Supervisor/Foreman DOS Certification Number
[AM061710
b.Project Monitor DOS Certification Number
AA000175
bb.Asbestos Lab DOS Certification Number
02/20/2009
b.Bid Date(mm/dd/yyyy)
IN/A
d.War k hours Sat-Sun Sat-Sun.
? E U M E
o 10 a What type of project is this?
❑Demolition Renovation
❑ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
0
0
U.
z
C
❑Glove bag
❑ Enclosure
❑ Cleanup
Full containment
•
12. Is the job being conducted:
anf00l ap.doc•10/02
❑ Encapsulation
❑ Disposal only
Other, specify:
J
b.Describe
7 Indoors? LJJ Outdoors?
Go To Top
Asbestos Notification Form•Page 1 of 3 II
A
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
1100083828
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
0
a.Total pipes or ducts(linear X)
c.Boiler,breaching,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
1305
b.Total other sort aces csquarelni
Lin.X.
Sq.X.
d.Insulating cement
Lin.X. Sq.fl. f.Trowel/Sprayer coatings
t
Lin f 1 Sq.ft
Lin.ft. S4 X.
insulation Lin.ft. Sq.X.
14. Describe the decontamination system(s)to be used:
SEAL CRITICALS W/6MIL POLY, ATTACH 3 STAGE DECONTAMINATION UNIT&INSTALL AIR
h.Transite board,wall board
Other,please specify:
[TILE&MASTIC
I Spay
1
Lin
Lin.ft.
Lin.ft
Sq.ft.
5
Sq.ft.
300
Lin. _IgX_It
15 Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
ACM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
N/A
a.Name of DEP ORda
c.Date(mmlddlyyyy)of Authorization
(N/A
e.Name of DOS Official
1
1
b.Title
J
L
d.DEP Waiver# _
Dt OS Official Title
g.Date(mmlddlyyyy)of Authorization h.DOS Waiver#
• 17 Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? i Yes❑No
B. Facility Description
'iOFFICE SPACE
o 1 Current or prior use of facility:
O 2. Is the facility owner-occupied residential with 4 units or less? ❑Yes a No
3.
MASSACHUSETTS HIGHWAY DEPARTMEN
a.Fealty Owner Name
° NORTHAMPTON
° c.Ci /Town
LL 4 KRISTEN WELLS
a.Name of Fadltty Owner's On-Site Manager
1
C c.cny/rown
811 NORTH KING STREET
b.Address
01060
d.Zip Code
anf001ap.doc•10102
d.Zip Code
413-582-0523
e.Telephone Number(area code and extension)
b.On-Site Manager Address
1413-743-3065
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa ea 2
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19 000
0
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100083828
Decal Number
B. Facility Description (cont.)
BURKE CONSTRUCTION
a.Name of General Contractor
ADAMS
C.City/fown
COMMERCE&INDUSTRY
L Contractor's Worker's Comp.Insurer
6. What is the size of this facility?
01220
d.Zip Code
J
6 RENFREW STREET
b.Address
1413-743-3065
e.Telephone Number)area cod and extension)
WC5312904 1 [11/04/2009
g.Policy Number h.Exp.Date(mm/dd/yyyy)
30,000 2
a Square Feet b.Number of floors
J
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
2.
IACCUTECH INSULATION &CONTRACTING
a.Name of Transporter
LUDLOW
c.City/Town
01056
d Zip Code
Transporter of asbestos-containing waste material
RED TECHNOLOGIES
a.Name of Transporter
PORTLAND
c.City/Town
06480
d Zip Code
3 l a.Refuse Transfer Station and Owner
4
c.City/Town
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
100 STATE STREET
b.Address
(413) 583.5500
e.Telephone Number
from removal/temporary site to final disposal site:
1173 PICKERING STREET
b Address
((860)342-1022
e Telephone Number
b.Address
d Zip Code
9000 MINERVA ROAD
c.Final Disposal Site Address
OH
e.State
144688
f Zip Code
e.Telephone Number
b. Final Disposal Site Location Owner's Name
WAYNESBURG
d.Citygown
g.Telephone Number
D. Certification
The undersigned hereby states, under the
o penalties of perjury,that he/she has read the
o Commonwealth of Massachusetts regulations
for the Removal, Containment or
Encapsulation of Asbestos,453 CMR a00 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.
LL
2
C
anNOlapdoc•10/02
HEATHER R. CREPEAU
a.Name
(OFFICE MANAGER
c Position/Title d.Date
1(413)583-5500 ACCUTECH
e Telephone Number f R p nl np
1100 STATE STREET
q.Address
b.Author
zed S
nature
01/23/2009
/dd
!LUDLOW
h City/Town
I 101056
I.Zip Code
Go To Top
Asbestos Notification Form•Page 3 of 3 II
Important
When filling out
forms on the
computer.use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100083766
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? L,(]Yes ❑No
b Provide blanket decal number if applicable:
2. Facility Location:
MASSACHUSETTS HIGHWAY DEPARTMENT
N me of Fadlity
NORTHAMPTON
c.City/Town
1.All sections of this
form must be
completed in order
to comply with
DEP notification
requirements of 310
CMR 715
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 6.12
3, Worksite Location:
PHASE 9 RMS 107,201, 2051
a.Building Name/Building Location
4. Is the facility occupied? {i Yes
5. Asbestos Contractor:
(ACCUTECH INSULATION &CO_
a,Name
(LUDLOW J
a City/Town
IAC000005
f.DOS License Number
(KRISTEN WELLS
h.Facility Contact Person_
6 (BRANDON E BESAW
a Name of On-Site_Supery so/FO ean__-
7, IURS
Blanket Decal Number
1811 NORTH KING STREET-
b Street Address
`-MA .� L01060 `(413) 582-0523
0.State e Zip Code f.Telephone Number
b.Building# ---��
No
NTRACTING
101056
d.Zip Code
a Name of Project Monitor - _-
IURS
8,
a Name of Asbestos Analytical Lab __
(02/09/2009 __ 1
o 9' a Project Start Date(mmlddlyyyy)
o 17:00-5:00
c,Work hours Mon-Fn.
o 10 a What type of project is this?
o ❑ Demolition U Renovation
• ❑ Repair U Other, please specify:
• 11. a. Check abatement procedures:
0
to
1
u-
2
a
❑Glove bag
❑Enclosure
❑ Cleanup
Full containment
0
12. Is the job being conducted
anf0o1apdoc•10/02
(]Encapsulation
Li Disposal only
LEI Other, specify:
C Wing
d Floor
1100 STATE STREET_
b.Address __
14135835500
e.Telephone Number
g. Contract Type: LJ Written ❑Verbal
I
I Contact Person's Title _—._-
[AS070407 _ -_ —_-.i
b.Staennsor/Foreman DOS Certification Number._
[AM061710 _ Nu ___ _-j
E.Project Monitor DOS Certifiwton mber ___ -_
IIAA000175 __
b.Asbestos Analytcal Lab DOS Certfcafon fJU=be .,_ _I
[02/20/2009 - - _ ___-_
- Ertl Date im mmYXYYI._-- -
dN/A _ _
-Work ho s Sat-Sun
e.Room
b.DesCrl
I C f
FEB - 2 2009
cnuCP d ApS BOAR➢f1F NFgtTH
O.Describe
D
j✓,i Indoors? [71 Outdoors?
Go T Top
Asbestos Notification Form•Page 1 of 3 I.
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100083766
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed, or
en�psulated:
a.Total pipes or ducts(linear X)
C.Boiler,breaching,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
I.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
14. Describe the decontamination system(s)to be used:
SEAL CRITICALS 6MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNIT&INSTALL AIRli
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)
0
0
IN
2100
t TolaTother surfacestsqua ar
I n J 1 d.Insulating cement Linn ft — Sq.fl. 1
Lin.n. Sq.n. —1 .,,.300 __-1
_ L TrowellSprayer coatings Vila X_-""- " g4;fl.
Lin.ft jSq X. -�
L 1� h Transite board,wall board [Lin fl Sq V-
{
�L n.X. 59 X_� t
N L 111600 .
__-_._ i.Other,please specify Sot,ft
Lin.ft. sa.X. __ _.__ _—_—
nj
-__—_
[TILE&MASTIC
[TILE
( Lin.X.-� Sq.X. - �-
ACMT(9B
ACMTO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED[ �
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
I —
N/A
a.Name o DEP Cir aI
Date( lddlyyyy)of Authorization__
c.N/A
e.Name of DOS Official
b.Title ----"�!
d.OEP Waiver#
f.D�OKival Title
q.Date(mm/tldryyyyl of Authorization
h.DOS Waiver#
17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A-F apply to this project?
B. Facility Description
'...OFFICE SPACE
1. Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or
3
0
LL 4
12
ss? (-_l Yes RI No
811 NORTH KING STREET i
b.Address
13-582-0523 )
Telephone Number area code and mdensloft
I
b.On-Site Manaager Address
1413-743-3065 -- -
e.Telephone Number(area code-and xtensio—n)
Asbestos Notification Form•Pa ea a 2 a
Yes fl No
less?
HIGHWAY DEPARTMEN
F ulity Owner Name______ ..— --
NORTHAMPTON I '.01060 14
CA /T w d_ZiPCOde__
KRISTEN WELLS __ J
a.Name of Fad Owner's On=SiteManager
_
-_-� d.Zip Code
C.City/Town
anf01 ap.doc•10/02
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19 000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
B. Facility Description (cont.)
5 BURKE CONSTRUCTION
a.Name of General Contractor 01220
MADAMS 11
- Code
c.CU rtowy nom---- -
COMMERCE&INDUSTRY ._.a
f.Contractor's Worker's Comp.Insurer
6. What is the size of this facility?
C. Asbestos Transportation and Disposal
Transporter of asbestos-containing material from site to temporary storage site(if necessary)
ACCUTECH INSULATION &CONTRACTIN_G Itl .Address STATE STREET____—_.
a.Name of Trans prter ( l �13 563-5500
LUDLOW _; d.Zip _ , (_ ) _----------�
d Zip Code e.Telephone Number
c.City/Town
2. Transporter of asbestoscon[ainingwoste material from removal/temporary site to final disposal site:
RED TECHNOLOGIES _ _,_ 173 PICKERING STREET__
_ --- p.Address
106480 t(860 —__--- —
�' 342-1022
) __-_ — _—-----
_—
m
100083766
Decal Number
6 RENFREW STREET _---_._._J
b.Address _—_—-----__.,.
413-743-3065 --_
Telepno a Numbe_ a a code and extens ny -1
WC5312904 ) '11110412009
.Pobc Numbe h.Exp.Dateimmadiyyyyi,
��30000 _ _ --_---_:
Square Feet b.Number of floors
—U
4
a.Name of Transporter
POD RTLANU —.—J
Tele hone Number I
_ J Zip_Coae—_l e_�-_ ---. --
b Addres _ l
a Refuse Transfer Station and Owner -_ _
_
. - tl Zip Code e Tel phone Number _.. --
c CityrTOw __. -
iM NERVA ENTERPRISES INC Owner's Name
I Site Location Name b Final Disposal S to L o c a t i o n
9000 MINERVA ROAD IWAYNESBURG —__
..
a city/Town
_ _ _—_- -------�
cr Final pls_posai Site ntltlre s I 44688 ] i ---
Gf= f.Zip Code g Telephone N mbe r
e.State
0
• D. Certification
N The undersigned hereby states, under the
io penalties of perjury,that he/she has read the
i0 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• to the best of this
is/her know edge and belief correct
ao
Z
anf001ap doc•10/02
HEATHER R.CREPEAU_
a.Name
OFFICE MANAGER
c_Position/Title �
x(413) 583-5500
eTelephone Number
100 STATE STREET
q AOtlress___._.... ,
!LUDLOW
it
n.Gib/toww
n
CI "NrICIr
y.AYuthorized SiSnature _
101/22/2009 I
tl_Dae mmldtllyny]_ 1
iACCUTECH ._..1
f Representing,
01056
I.Zip Code
Go To Top
Asbestos Notification Form•Page 3 of 3 II
Important
When filling out
forms an the
computer.use
only the tab key
to move your
cursor-do not
use the return
key.
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
k00083150
Decal Number
INSTRUCTIONS
1.All sections of lhi
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR7.15
and the Division
of Occupational
Safety(00S)
notification
requirements of 453
CMR612
A. Asbestos Abatement Description
a.Is this facility fee exempt-city,town, district, municipal housing authority,owner-occupied
residence of four units or less? 1]Yes Li No ----
b. Provide blanket decal number if applicable:
2. Facility Location: _�
!MASSACHUSETTS HIGHWAY DEPARTMENTI
a.Name of En:PR ---
'NORTHAMPTON J 1MA
c.City/Town d.Slate
3. Workste Location.
PHASE 8 RMS 101,103,201J
a.Building Name/Building Location
Is the facility occupied? `L Yes ❑No
b.Building k
Asbestos Contractor:
ACCUTECH INSULATION
a.Name
LUDLOW
c.City/Town
1AC000005
f.DOS License Number
KRISTEN WELLS
h F l'ty Contact Person
BRANDON E BESAW
6
Name of SUpevso/F0reman
URS ——
Blanket Decal Number
1811 NORTH KING STREET
b Street Addess ---�
`01060 _1 1(413)582-0523
e Zip Code f.Telephone Number
1 L I r ^ I J
c Wing d.Floor e Room
&CONTRACTING Iti
_
01056 _I
a/in
a.Name f Prded Monitor ---_l
URS __-- ---'
6_ a.Name of Asbestos Analytical Lab _.___---I
01/1912009 _----_I
9 a.Project Start fat 1mal.g yYY)
o 7:00-5:00
c.Work hours Mon-Fri.
0
o Demolition
[]Repair
0 a What type of project is this?
VT Renovation
J Other, please specify:
• 11. a. Check abatement procedures:
Glove bag r Encapsulation
Enclosure° ❑ -
osure Disposal only
°
❑Cleanup Li' Other, specify:
Full containment
z
C
U
,I
F100 STATE STREET
b.Address __.__
4135835500
e.Telephone Number
g. Contract Type: RI Written El Verbal
ctPerson's rso
L Contact TtleAS070407
e.Supervisor/Foreman DOS Certification Number
[AM061710
b_Project Monitor DOS Certificabo Number
AA000175
b Asbe51o5 AnalYt cal Lab DOS Certification Number
10113012009
b.End Date(m
1■/A
0.Work hours
J
CAULKING REMOVAL
b Describe
12. Is the job being conducted: V Indoors? IJj Outdoors?
anf0ol ap doc•10/02
Go To Top
Asbestos Notification Form•Page 1 of 3 U
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100083150
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or
encapsulated
e (2100
otal pipes or ducts(linear X) FTotzl other surfaces(square l
0
0
N
i0
0
c.Bailer,breaching,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
14. Describe the decontamination system(s)to be used:
SEAL CRITICALS W/6MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNITS INSTALL AIR?
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
621±1121(91_______
d Insulating cement
r It Lin.X. Sq.fl. 1
' CTmwellSprayer coatings
Lin.X Sq X
I
-! h.Transite board,wall board
Lin fl.--- Sq X
r—
I ( j,Other,please specify
Lin ft_.. Sg-ft
( (TILE 8 MASTIC
Lin ft Sq,fl. I.Specify
Lin.ft. , 1300
Sq f
r
1I
LT ft_ Sq ft
I _ 1800
L ft —__ Sq fl..
ACM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED
g__--__ l
16. For Emergency Asbestos Operations. the DEP and DOS officials who evaluated the emergency
N/A _i
b:Title
a.Name of DEP Official -___ --) ! '-
-"_- --J
d.DEP Waiver#
c.Date(mmlddlyyYY)of Authorization
___ _ -- ---'—
N/A
f.DOS Official Title
e.Name of DOS Official _ -'- "" -
g.Date(mmltltl?yyYY)of A mo zat on
--- -_- h DOS Waiver#
17. Do prevailing wage rates as per M.G L c. 149, §26 27 or 27A—F apply to this project'? {'.Yes--,,No
B. Facility Description
1. Current or prior use of facility:
2. Is the facility owner-occuPied residential with 4 units or less? [1.7,Yes CZ No
MASSACHUSETTS HIGHWAYDEPARTMEN NORTH STR
KING STREET
F Tt Owner Name
'OFFICE SPACE
3.
r
v ---- Ig13-562-0523
001060
NORTHAMPTON -J -- mberyarea code and extension)._
c Ctvrtown ____.__Slip ---, r
-_-� Code e..Telephone
u — ---1
I
KRISTEN WELLS - --- I b On-site Ma age Address
---..
u_ 4 .__ _--.�
pager _ _ —..
C.City/Town --- e Telephone ne Number
a Name of Fadlry Owners0 St
Manager
Zip Code e YeleDhone Nu (area code and extension)
Asbestos Notification Form•Pa ee 2a
anf001apdoc•10/02
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
:100083150
Decal Number
B. Facility Description (cont.)
(BURKE CONSTRUCTION _ J
5' a.Name of General Contractor
1ADAMS _.i L1220
C.City/Town _-______d-ZJp Cade
COMMERCE B INDUSTRY
f.Contractors Workers Comp.Insurer
6. What is the size of this facility?
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
1ACCUTECH INSULATION &CONTRACTING 1 1100 STATE STREET
a.Name of Transporter _ —---
b.A d d r e s s _—
1LUDLOW __- 101056 _ 1s13) 583-5500
c.City/Town d Zip Code e.Telephone Number
2. Transporter of asbestos containing waste material from removal/temporary site to final disposal site:
1RED TECHNOLOGIES ____ ._i (173 PICKERING STREET
a.Name b.Address
!PORTLAND nsponer --j 106480 1(860) 342-1022
aTowe J cr.Zi Code e Telephone Number
c.Ciry/rown _—_—.—.__—____. 2
I
16 RENFREW STREET
b.Address __ — --------
1413-743-3065
e.Telephone Number(area code and extension)
l _-_
(WC5312904 111104/2009
.Pobc Number h.ExP.Date(mmldtll
a Square Feet b.Number of floors
3. 1. _..._I
a.Refuse Transfer Station and Owner 1
c.City/Town —� d Zip Code
4. 1MINERVA ENTERPRISES INC _I
F D' p al Site Location Name
9000 MINERVA ROAD __—. J
c.Final Dis osal Site Address ---�
OH __ 144688 i
e.State I.Zip Code
O
o D. Certification
N
The undersigned hereby states,under the
o penalties of perjury,that he/she has read the
O 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
iO to the best of his/her knowledge and belief.
0
u_
Z
Q
anfODlap.doc•10102
b.Address
e Telephone Number_,_
b.Final Dis °sal Site Location Owners Name
WAYNESBURG
fd_CityRown_"-__...___
9.Telephone Number
(HEATHER R.CREPEAU
a Name
IOFFICE MANAGER
c Position/Hie
[(In 3)583-5500
e.Telephone Number_
1100 STATE STREET
q.Address —.
1LUDLOW __
b.City/Town
b.Authorizetl 5•nature
10110612009 _-__,
d.Date mmldtll yy)__ __,
lACCUTECH
f R resenting
L1056
I.Zip Code
7
Go To Top
Asbestos Notification Form•Page 3 of 3 U
(01/0712009
1.Original Start Date(mmldd/yyyy)
LI
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key
Phr . 9
Massachusetts Department of Environmental Protection
1100079180 I Dec al Number
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
A. Facility Location
(MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
1811 NORTH KING STREET
2.Street Address
I NORTHAMPTON
3.City
14135820523
6.Telephone Number
1 IMA
4.State 5 Zip Code
B. Project Cancelled
I I
Check here if this project is/was cancelled.
C. Project Dates
(
(
3.Latest Revised Start Date(mmIddlyyyy)
101/23/2009
2.On inat End Date mmld
ALA
4 Latest Revised End Date(mm/dd/yyyy)
D. Revised Project Dates
102102/2009 102/13/2009
1.Revised Start Date(mmidd/yyyy) 2.Revised End Date Date(mm/dd/yyyy)
E. Other Project Revisions
F. Revision History
anfO6pdm.doc•rev.2/5/04
JAN - 7 2009
NORTHAMPTON BOARD OF HEALTH
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
00079180
Decal Number
G. Certification
The undersigned hereby states,under the penalties of perjury,that he/she has read the CMm ono and 310 of
Massachusetts regulations for the Removal.Containment or Encapsulation of Asbestos,453
CMR 7.15,and that the information contained in this notification is true and correct to the best of his/her knowledge
and belief.
'HEATHER R.CREPEAU
1, Name
'OFFICE MANAGER
2. Position/Title
IACCUTECH INSULATION &CONTRACTING
4. Representing
1100 STATE STREET
h( � CJ
Authorized Slanature
01/06/2009
3. Date lmmidd/WVVI
1(413) 583-5500
5. Telephone
6. Address -----
'LUDLOW 101056
0. Zip Code
). City/Town
anto6pdrn doc•rev.215104
112/18/2008
1.Original Start Date(mmldd/yyyy)
61108/2009
3.Latest Revised Start Date(mmlddlyyyy)
nportant:
hen filling out
inns on the
omputer,use
,nly the tab key
move your
ursor-do not
Ise the return
ey.
ousk
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention—Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
Decal Number
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
A. Facility Location
(MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
811 NORTH KING STREET
2.Street Address
(NORTHAMPTON
3.City
14135820523
6.Telephone Number
1 1MA
4.State
5.Zip Code
B. Project Cancelled
I I
Check here if this project is/was cancelled.
C. Project Dates
11213012008
2.Odginal End Date Immtdd/yvyy)
101/16/2009
4.Latest Revised End Date(mmlddlyyyy)
D. Revised Project Dates
101/16/2009
1.Revised Start Date(mm/ddlyyyy)
101/23/2009
2.Revised End Date Date(mm/ddlyyyy)
E. Other Project Revisions
F. Revision History
EDEP: 12/15/2008 02:02:22 PM
anfo6pdrn doc-rev.2/5/04
IS C LS ll 1ff
LS
JAN - 7 2009 J
NORTHAMPTON BOARD OF HEALTH
0
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
1100079176
Decal Number
G. Certification
The undersigned hereby states, under the penalties of perjury,that he/she has read the 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.
'HEATHER R.CREPEAU
1. Name
(OFFICE MANAGER
2. Positionfrille 3 Dalelmm/dd/WW) __—.__ ----1
'ACCUTECH INSULATION &CONTRACTING j 13)583-5500 I
4. Representing 5. Telephone
1100 STATE STREET
6. Address
Authorized Signa ure
101/06/2009
'LUDLOW
]. City/Town
anfO6pdm.doc•rev.2/5/04
01056
8. Zip Code
1100079172
A'
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
Mtn
Decal Number
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
A. Facility Location
(MASSACHUSETTS HIGHWAY DEPARTMENT
t Name of Facility
1811 NORTH KING STREET
2.Street Address
_-_ __] [MA
3.City -... �..-. 4.State
'4135820523 I
6.Telephone Number
5.Zip Code
B. Project Cancelled
1
Check here if this project is/was cancelled.
C. Project Dates
112/03/2008
1.Ori•inal Start Date mm/ddl
12/18/2008
3.Latest Revised Start Date(mm/ddlyyyy)
III
1 112/12/2008
,L at IE dJ to lmMddlvv D
112/31/2008
4.Latest Revised End Date(mm/ddlyyyy)
D. Revised Project Dates
I.Revised Start Date(mm/dd/yyyy)
I 01/0612009
2 Revised End Date Date(msdtllyyyy)
E. Other Project Revisions
F. Revision History
EDEP: 12/03/2008 08:18:04 AM
EDEP: 12/12/2008 03:28:18 PM
FDPP: 12/18/2008 08:03:10 AM
antO6pdrn doc•rev.2/5/04
ECIEHVIE
JAN - 2 2009
NORTHAMPTON BOARD OF HEALTH
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
1100079172
Decal Number
I
G. Certification
The undersigned hereby states,under the penalties of perjury,that he/she has read the 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.
(HEATHER R. CREPEAU
1. Name Authonzed ignat
(OFFICE MANAGER
2 Position/Title 3. Date(mm/dd/ww)
(ACCUTECH INSULATION &CONTRACTING J 1(413) 583-5500
4. Representing 5. Telephone
100 STATE STREET
6. Address _.
1
2/30/2008
LUDLOW
7. City/Town
anfO6pdrn.doc•rev.2/5/04
[01056
8. Zip Code