76 Asbestos Notification Form 2004 ACE ASBESTOS REMOVAL AND INSULATICaj'
a.Name
1 NORTH FIELD
c.City/Town
IAC000006
f.DOS License Number
!ED SHEARER
h.Facility Contact Person
EDWARD D SHEARER
a.Name of On-Site Supervisor/Foreman
RAYMOND J BRESNAHAN
a.Name of Project Monitor
Important
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
Mk
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100009320
Decal Number
1�N ■11
OCT 4 2nn1
A. Asbestos Abatement Description
1. a. Is this facility fee exempt-city, town, district, municipal housing authority,owner-
residence of four units or less? 12 Yes ❑No
-occupied
b. Provide blanket decal number if applicable:
2. Facility Location:
MCGEE RESIDENCE
a.Name of Facility
Northampton
c.Cdy/Tovm
3. Worksite Location:
1.All sections of this
form must be
completed in order
to comply with 4
DEP notification
requirements of 310
CMR e 5
and the Divisor
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 6.12
aapt
LL
Z
Q
■ anfoDlap.doc•10/02
6.
7.
8.
9
Blanket Decal Number
BASEMENT
MA
d.State
176 CRESCENT STREET
b.Street Address
101060
a Building Name/Building Location b.Building#
Is the facility occupied? Z Yes U No
Asbestos Contractor:
101360
d.Zip Code
e.Zip Code
(413)586.6529
f Telephone Number
c.Wing d.Floor
e.Room
716 PINE MEADOW ROAD
b.Address
4134980201
e.Telephone Number
g. Contract Type: S Written
I I Verbal
1
ENVIRONMENTAL SAMPLING&TESTING
a.Name of Asbestos Analytical Lab
10/04/2004
a.Project Start Data(mm/dd/yyyy)
8:30-4:30P
c.Work hours Mon-Fri.
10. a. What type of project is this?
❑ Demolition [ Renovation
❑ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
O
Glove bag
❑ Enclosure
❑Cleanup
Full containment
S
12. Is the job being conducted
7 Encapsulation
❑ Disposal only
❑Other, specify:
• Indoors?
(SUPERVISOR
i.Gonad Person's Title
IAS070245
b.Supervisor/Foreman DOS Certification Number
AM031604
b.Project Monitor DOS Certification Number
AA000132
b.Asbestos Analytical Lab DOS Certification Number
10/07/2004
b.End Data(mmfddlyyyy)
NONE
d.Work hours Sat-Sun.
b.Describe
b. Describe
Outdoors?
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Asbestos Notification Form•Page 1 of 3 IN
o
N
0
0
0
Z
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100009320
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing
encapsulated:
[235
a.Total pipes or duds(linear ft)
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
Materials(ACM)to be removed, enclosed, or
0
-Iota!other surfaces(square ft)
P
Lin.ft.
235
n.t
Lin.ft.
Sq.fl.
d.Insulating cement
Eq.R. f Trowel/Sprayer coatings
Sq.ft. h.Transits board,wall board
S
n.ft.
Lin.ft.
I.Other,please specify:
Lin.f. Sq.fl.
Lin.R. Sq.%.
Lin fl. q$
Lin.ft. Sq.ft.
14. Describe the decontamination system(s)to be used:
I.Specify
THREE CHAMBER DECON WITH WARM WATER SHOWER,TYVEK SUITS,HEPA VAC FOR CLEII
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
i REWET ASBESTOS AND SEAL IN DOUBLE,LASELLED POLY BAGS BEFORE REMOVAL FRON
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
a.Name of DEP Offiaal
0.The
c.Date(mm/dd/yyyy)of Authorization
d.DEP Waiver,/
e.Name of DOS Official
g Date(mmldNyyyy)of Authorization
f.DOS Urfidal Title
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 R1 No
B. Facility Description
1. Current or prior use of facility:
RESIDENCE
2• Is the facility owner-occupied residential with 4 units or less? l7 Yes ❑ No
3•
4
J
DICK MCGEE
a.Fadlity Owner Name
NORTHAMPTON
c.City/Town
01060
d.Zip Code
N/A
anf001ap doc•10/02
a.Name of Fadlity Owners On-Site Manager
c.City/Town
d.Zip Code
76 CRESCENT STREET
b.Address
413-586.6529
e.Telephone Number(area code and extension)
b.On-Site Manager Address
e Telephone Number(area code and extension)
Asbestos Notification Form•Pe e 2 of 3 U
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
m
MS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100009320
7
Decal Number
B. Facility Description (cont.)
5
ACE ASBESTOS REMOVAL&INSULATION
a.Name of General Contractor
NORTHAMPTON
c.CM/Town
GRANITE STATE INS CO
f Contractors Worker's Comp.Insurer
6. What is the size of this facility?
01360
d.Zi
Code
716 PINE MEADOW RD
b.Address
1413.498-0201
e.Telephone Number(area code and extension)
10910112005
h Exp.Date(mnVddlyAy)
12
WC2123724
g.Policy Number
2400
a.Square Feet b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
ACE ASBESTOS REMOVAL&INSULATION c
a.Name of Transporter
NORTHFIELD
01360
716 PINE MEADOW RD
b.Address
(413)498-0201
t City/Town d.Zip Code e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
3
4
WASTE MANAGEMENT N.E.E.T.
a.Name of Transporter
PORTLAND,CT
c.City/Town
06480
d.Zip Code
N/A
a.Refuse Transfer Station and Owner
c.City/Town
203 PICKERING STREET
b.Address
(860)342-0667
e.Telephone Number
b.Address
P
d.Zip Code
TURNKEY LANDFILL(WASTE MGT NH)
a.Final Disposal Site Location Name
17 ROCHESTER NECK ROAD
C.Final Disposal Site Address
INN
e.State
03839
Zip Code
e.Telephone Number
[WASTE MANAGEMENT OF NH
b.Final Disposal Site Location Owner's Name
ROCHESTER
d.City/Town
(603)330-0217
g.Telephone Number
D. 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.
EDWARD D SHEARER
a.Name
PRESIDENT
C.Positron/Title
(413)498-0201
e.Telephone Number
716 PINE MEADOW RD
q.Address
b.Authorized Signature
09/1712004
d.Date(mmlddtylV)
ACE ASBESTOS REMOV
I.Representing
NORTHFIELD
h.City/Town
01360
i.Zip Code
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• anf001 ap doc•10/02 Asbestos Notification Form•Page 3 of 3•
Important
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
1.
oat
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100008236
Decal Number
OCT 4
All sections of this
tor)must be
competed in order
to comply with
DEP notification
requirements of 310
CMR 9.15
and the Division
of O¢upational
Safety(DOS)
notification
requirements of 453
CMR 6.12
0
N
A. Asbestos Abatement Description
1. a. Is this facility fee exempt-cityjown, district, municipal housing authority, owner-occupied
residence of four units or less? !YYes ]No
b. Provide blanket decal number if applicable: �Blanket Decal Number
2. Facility Location:
1 MCGEE RESIDENCE
a.Name of Facility
[Northampton
c.Cly/Town
3. Worksite Location:
EXTERIOR SIDING
a.Building Name/Building Location
4. Is the facility occupied?
6
7
8
9
76 CRESCENT STREET
Yes
MA
O.State
b.Building*
No
Asbestos Contractor:
MACE ASBESTOS REMOVAL AND INSULATIOO'
a.Name
NORTHFIELD
c.City/Town
AC000006
f.DOS License Number
01360
d.Zip Code
b.Street Address
01060
IED SHEARER
h.Faolky Contact Person
EDWARD D SHEARER
a.Name of On-Site Supenjso
Foreman
N/A
a.Name of Project Monitor
N/A
a.Name of Asbestos Analytical Lab
109/23/2004
a.Project Start Data(mmldd/yyyy)
8:30-4:30P
c.Work hours Mon-Fri.
1(413)586.6529
e.Zip Code f.Telephone Number
c Wng d.Floor
e.Room
716 PINE MEADOW ROAD
b.Address
4134980201
e.Telephone Number
g. Contract Type: U Written
❑Verbal
SUPERVISOR
.. 0 10. a.What type of project is this?
O ❑ Demolition n Renovation
❑Repair ❑ Other, please specify:
11. a. Check abatement procedures:
0
i LL
aNING
2
d
❑Glove bag
• Enclosure
❑Cleanup
❑ Full containment
❑ Encapsulation
Disposal only
❑ Other, specify:
i.Contact Person's Title
AS070245
b.Supervisor/Foreman DOS Certification Number
N/A
b.Project Monitor DOS Certification Number
N/A
b.Asbestos AnaNtical Lab DOS Certification Number
09/24/2004
b.Bid Date(mmlddt yy)
NONE
O.Wads hours Sat-Sun.
b.Describe
b.Describe
12. Is the job being conducted: ❑ Indoors? n Outdoors?
• anf001ap.doc•10/02
Go To Top
Asbestos Notification Form•Page 1 of 3•
N
17 Do prevailing wage rates as per M.G.L.c. 149, §26, 27 or 27A—F apply to this project? ❑Vest-71 No
rid
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100008236
'Decal Number
A. Asbestos Abatement Description (cont )
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
i0
a.Total pipes or duds Qinear ft)
c.Boiler,breathing,dud,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
i.Cloths,woven fabrics
Ir.Thermal,solid core pipe
insulation
2000
b.Total other surfaces(square ft)
Lin.ft.
L J
Lin.ft.
Lin.ft.
r
Lin.
ft d.Insulating cement
Sg.Sq.ft.
Sq.ft.
So.ft.
Lin.ft. Sq.ft.
14. Describe the decontamination system(s)to be used:
f.Trowel/Sprayer coatings
h.Transite board,wall board
j Other,please specify.
'SIDING
I.Specify
Lin.ft. Sq.ft.
Lin.ft. Sq.ft.
Lin.ft. Sq. li
1120013
Lin.ft.
iN/A DISPOSAL ONLY OF BAGGED TRANSITE SIDING.
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
IREWET ASBESTOS AND SEAL IN DOUBLE,LABELLED POLY BAGS BEFORE REMOVAL FRON
16. For Emergency Asbestos Operations, the DEP and DOS&tibia's who evaluated the emergency:
a.Name of DEP Official
rDate(mndddryyyy)of Authorization
li
e.Name of DOS Official
I
g Date(mmltlWyyyy)of Authorization
b.Title
d.DEP Waiver#
Ofiaal Title
.DOS Waiver#
N
o
o
0
MIM LL
z
C
B. Facility Description
1. Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units
[RESIDENCE
3.
4.
DICK MCGEE
a.Fadlity Owner Name
(NORTHAMPTON
c.City/Town
101060
d.Zip Code
N/A
a.Name of Facility Owner's nSite Manager
' I
an1001apdoc•10/02
c.City/Town
d.Zip Code
or less?
Yes ❑No
76 CRESCENT STREET
b.Address
413-5864529
e.Telephone Number(area code and e
en
on)
b.On-Site Manager Address
e.Telephone Number(area code and extension)
Asbestos Notification Forth•Pa e 2 of 3 I.
•
e•• fiet
Commonwealth of Massachusetts
LiAsbestos Notification Form ANF-001
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
Z
wriza
C
1100008236
Decal Number
B. Facility Description (cont.)
5.
lACE ASBESTOS REMOVAL 8 INSULATION
a.Name of General Contractor
NORTHFIELD 01360
c.City/Town O.Zip Code
GRANITE STATE INS CO
f.Contractors Workers Comp.Insurer
6. What is the size of this facility?
716 PINE MEADOW RD
b.Address
413.498-0201
e.Telephone Number(area code and extension)
:WC2123724 09/01/2005
g.Policy Number h.Exp.Date(mm/dtlhyyy)
2
2400
a.Square Feet b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
!ACE ASBESTOS REMOVAL 8 INSULATION
a.Name of Transporter
NORTHFIELD
c City/Town
01360
d.Zip Code
1716 PINE MEADOW RD
b.Address
(413)498-0201
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
1 WASTE MANAGEMENT N.E.E.T.
a.Name of Transporter
PORTLAND,CT
c.City/Town d.Zip Code
3. IIN/A
a.Refuse Transfer Station and Omer
i
c.
06480
CV/Town d.Zip Code
4. TURNKEY LANDFILL(WASTE MGT NH)
a.Final Disposal Site Location Name
7 ROCHESTER NECK ROAD
c.Final Disposal Site Address
INN
e.State
103839
1203 PICKERING STREET
b.Address
(860)342-0667
e.Telephone Number
b.Address
f.Zip Code
e.Telephone Number
WASTE MANAGEMENT OF NH Ji
b.Final Disposal Site Location Owners Name
ROCHESTER
d.City/Town
(603)330-0217
g.Telephone Number
D. 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.
anf001ap.doc•10/02
EDWARD D SHEARER
a.Name
PRESIDENT
c.Position/Tite
(413)498-0201
e.Telephone Number
b.Authorized Signature
109/092004
d Date(mm/tld/yyyy)
MACE ASBESTOS REMOV.
T Representing
716 PINE MEADOW RD
p.Address
NORTHFIELD
h.City/Town
101360
i.Zip Code
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Asbestos Notification Form•Page 3 of 3■