36 Asbestos Notification Form 2004 i
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Commonwealth of Massachusetts
Asbestos Notification ! r- ! ° ;
.Asa 1
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A. Asbestos Abatement Descript -C;m , AL DO HEAL- TH I,
1. a. Is this facility fee exempt-city,town,distri usthg authority, owner-occupied
residence of four units or less? ❑Yes No
b. Provide blanket decal number if applicable:
ma of this a.Building Name/Building Location
be
In order
with 4. Is the facility occupied? fA Yes
ztion
nts of 310
100005891
Decal Number
Affix Asbestos
Notification Decal
Here
2. Facility Location'.
RENTAL
Name of Each
Northampton
c.City/Town
3. Worksite Location:
BASEMENT
vision
iDonal
DS)
ints of 453
MA
dState
p.Building#
❑No
Asbestos Contractor:
ACE ASBESTOS RE MOVALANDINSULAT
a.Name
NORTHFIELD
c.0
A0000006
S Licenses
MARK LANDY
h I ontact Person
EDWARD D SHEARER
6. a.Name of On-Site Foreman
RAYMOND J BRESNAHAN
a.Name of Pro Monitor
ENVIRONMENTAL SAMPLING 8 TESTING
8. Name of Asbestos Anal cal Lab
06/28/2004
O 9 a.Pro'ect Start Date mid
O 8:30-4:30P
c.Work hours Mon-En.
• 10. a. What type of project is this?
01360
d.Zip Code
Blanket Decal Number
36 MONROE
b.Street Addres
01060
e.Zip Code
C.Wing
STREET
(413)625-6999
f.Telephone Number
d.Floor
716 PINE MEADOW DOW ROAD
bb.Address
—
413498020__1
e.Telephone Number
g. Contract Type:
DESIGNER
Contact Person's Title
AS070245
b.Su•ervisor/Foreman DOS Certification Number
AM031604
b.Pro ect Monitor DOS Certification Number
AA000132
b.Asbestos Anal bcal Lab DOS Ce
06/29/2004
b.End Date(mmiddi
e.Room
lad Written j]Verbal
lion Number
o ❑ Demolition [2] Renovation
• ❑ Repair ❑ Other, please specify'.
• 11. a. Check abatement procedures:
io ]Glove bag Encapsulation
O
❑Enclosure L Disposal only
o ❑ Other, specify:
❑ Full containment
containment
12. Is the job being conducted: I,J' Indoors? ❑'Outdoors?
LL
z
C
0
oM1 hours Sat-Sun.
b Describe
b.Describe
tt001 ap.doc•10102
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Asbestos Notification Form•Page 1 of 3
1100005891
3
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
Decal Num
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated'
160
nail pipes or ducts(linear ft
c.Boiler,breaching,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
bo total of e ace
r su square )
-0
d Insulating cement
Lin.ft. Sq.ft
1160 J I I f.Trowel/Sprayer coatings
Lin.ft. q.ft.
—1 I
h_Transite board,wall board
Lin ft. Sq ft
woven fabncs J I j.Other,please specify:
i.Cloths,w Lin. S
k.Thermal,solid core pipe I Lin.ft. I I
Sp.fl Specify. I.Speci
insulation
14. Describe the decontamination system(s)to be used:
'THREE CHAMBER DE-CON WITH WARM WATER SHOWER,TYVEK SUITS,HEPA VAC FOR CLEI
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.'14(L(g):
Lin.ft
1 Lin.ft. Sq.ft.
Lln.R__J tSq.ft.
p II
Lin.ft. Sq.ft_
RE WE T ASBESTOS AND PACK IN DOUBLE,SEALED AND LABELLED POLY BAGS BEFORE R
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
71 I
b.Tltle
a.Name of DEP Official
c.Date(mmlddlyyyy)of Authorization
e.Name of DOS Official
g.Date(mMddlyyyy)of Authorization
N 26, 27 or 27A—F apply to this project? ❑Yes!,] No
0 17. Do prevailing wage rates as per M.G.L. c. 149, §
d.DEP Waiver#
fl SOffi°al Title
h.DOS Waiver#
o B. Facility Description
ry
o 1. Current or prior use of facility:
0
I-RENTAL-RESIDENTIAL
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes 0 No
1JORDI HEROLD
• F Ty Owner Name — —--�
o NORTHAMPTON I 101060
d Zip Code
0 c City/Town
LL 4 MARK LANDY
a.Name of Facility Owners On-Site Manager
ASHFIELD 101330
• c.City/Town d.Zip Code
mf001 ap.doc•10/02
13 MASSASOIT AVE.
b.Address
413-625-6999
e.Telephone Number(area code and extension)
P.O.BOX 61
b.On-Site Manager Address
413-625.6999
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa ea a 2
3
ranter
s must
with the
taste
flans
310
9.00
9.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100005891
Decal Number
B. Facility Description (cont.)
[ACE ASBESTOS REMOVAL&INSULATION
5. a.Name of General Oontmdor
1NORTHFIELD,MA
c.City/Town
[GRANITE STATE INS. CO.
f.Contractors Worker's Comp.Insurer
6. What is the size of this facility?
101360
d.Zip Code
[716 PINE MEADOW RD
b-Address
1413498.0201
e.Telephone Number(area code and extension)
1WC2123724 1 109/01/2004 I
q.Policy Number h.Exp.Date(mm/dd/yyyy)
[1800
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&INSULATION T
a.Name of Transporter
1NORTHFIELD,MA
C.City/Town
1716 PINE MEADOW RD
b.Address
101360 J (413)498-0201
d.Zip Code e.Telephone Number
2. Transporter of asbestos-containing waste material from removaVtemporary site to final disposal site:
[WASTE MANAGEMENT N.E.E.T. ____I 1203 PICKERING STREET
a.Name of Transporter b.Address
PORTLAND,CT 1 106480 J I(86o)342-0667
c.City/Town d.Zip Code e.Telephone Number
3. IN/A
a.Refuse Transfer Station and Owner
L__Ciry/Town d.Zip Code
4. [TURNKEY LANDFILL(WASTE MGT. NH)
a.Final Disposal Site Location Name
197 ROCHESTER NECK ROAD 1
c.Final Disposal Site Address
1NH 1 103839 !,
e.State f.Zip Code
L
b.Address
em
�o
• D. Certification
--_N
e.Telephone Number
1 WASTE MGMT OF NH
b.Final Disposal Site Location Owners Name
1 ROCHESTER
d.Ciry/Town
1(603)330-0217
g.Telephone Number
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
o to the best of his/her knowledge and belief.
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1(001ap.doc•10/02
[EDWARD D SHEARER 1
a.Name
[PRESIDENT
c Position/Title
1(413)498-0201
e.Telephone Number
1716 PINE MEADOW RD
s.Address
'(NORTHFIELD,MA
h.City/Town
b.Authorized Signature
106/14/2004
d.Date(mrWdd/vwv)
ACE ASBESTOS REMOVJ
f.Representing
1 101360
I.Zip Code
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Asbestos Notification Form•Page 3 of 3 NI