274 Asbestos Notification Form 2004 CommonwealthMassachusetts
J Asbestos Notification Form ANF-001
ortant:
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A. Asbestos Abatement Description
1. Facility Location:
Academy of Music
Name of Facility
Northampton
City/Town
274 Main Street
776354
Please Enter Decal# _
776354
Worksite Location:
Throughout
Building name,#,wing,floor,room
MA
State
Street Address
01060 (413) 584-8435
Zip Code
2. Is the facility occupied? ❑Yes ❑ No
3. Asbestos Contractor:
AccuTech Insulation 8 Contracting,
Name
'RUCTIONS Ludlow, MA
I sections of
arm must be AC000005
Meted in order DOS License#
mply with
notification
rements of
0,MR 7.15
he Division 4.
:cupational
y(DOS) 5
cation
rements of
MR 6.12 6.
01056
City/Town
ibmit Original
to:
monwealth of
lachusetts 7,
stos Program
lox 120087
an MA
2-0087
Zip Code
Keith Jenkins
Facility Contact Person
Anthony Roy
�.Talerobanr
L ' N fl VI Cc 17)
�• ;'
JUN - 82004 ( l
BOARD OF REALTNI
111
100 State Street, P.O. Box 376
Address
(413) 583-5500
Telephone
Contract Type: ®Written ❑Verbal
President
Contact person's title
AS71233
Name of On•Site Supervisor/Foreman
To be determined
DOS Certification#
Name of Project Monitor
To be determined
DOS Certification#
Name of Asbestos Analytical Lab
06/28/04
DOS Certification#
07/02/04
Project Start Date
7 AM to 4 PM
End Date
N/A
Work hours Mon-Fri.
8. What type of project is this?
❑Demolition ® Renovation
❑ Repair ❑ Other, please specify:
9. Check abatement procedures:
Work hours Sat-Sun.
® Glove bag ❑ Encapsulation
❑ Enclosure ❑ Disposal only
❑Cleanup ❑ Other, specify:
E Full containment
10. Is the job being conducted: ® Indoors? ❑ Outdoors?
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Asbestos Notification Form•Page 1 of 4
r*
Commonwealth`�I Massachusetts
j Asbestos Notification Form ANF-001
776354
Please Enter Decal it
A. Asbestos Abatement Description (cont.)
11. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
710
pipes or ducts(linear ft)
Boiler,breaching,duct,tank surface
coatings
Corrugated or layered paper pipe
insulation
Spray-on fireproofing
Cloths.woven fabrics
Thermal,solid core pipe insulation
M.ft sq.ft
lin.ft sq.ft
lin.ft sq.ft
lin.ft sq.ft
550/
tin.ft sq.ft
135
other surfaces(square ft)
Insulating cement
Trowel/Sprayer coatings
Transite board,wall board
Other,please specify:
160 Iln ft boiler rope,100 sq.ft
of dahrla 30•zn ft of linnlaum
lin.ft sq.ft
lin.ft sq.ft
15
lin.ft sq.ft
lin.ft sq.ft
12. Describe the decontamination system(s)to be used:
Seal criticals with 6 mil poly, pre-clean lay drop cloth using the negative pressure glovebag method.
Two layers of 6 mil poly on the walls and floor(where applicable)attached 3 stage decon unit.
13. 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 company vehicle to
dumn sits
14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
N/A
Name of DEP official Title
Date of Authorization Waiver#
N/A
Name of DOS official Title
Date of Authorization Waiver#
15. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? 'r4 Yes 0 No
B. Facility Description
1. Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or less? ['Yes ® No
210 Main Street
3. Address
Commercial
City of Northampton
Facility Owner Name
Northampton 01060 413-247-0155
City/Town Zip Code Telephone
Bob Aquadro same as above
4. Name of Fadlity Owners On-Site Manager Address
City/Town
(cation-Academy•9/02
Zip Code Telephone
Asbestos Notification Form Page 2 of 4
Commonwealth Massachusetts
J Asbestos Notification Form ANF-001
-render
is must
•with the
Vaste
n
moos 310
9.000
776354
Please Enter Decal#
B. Facility Description (cont.)
N/A
5' Name of General Contractor
City/Town Zip Code
Granite State Insurance Company
Contractors Worker's Comp. Insurer
6. What is the size of this facility?
Address
Telephone
7252577
Policy#
15,000
Square Feet
11/04/03
Exp.Date
2
#of floors
Contractor
;ign this form
IS notification
3es
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site (if necessary)to final
disposal site:
AccuTech Insulation & Contracting, Inc. 100 State Street, P.O. Box 376
Name of transporter Address
Ludlow, MA 01056 (413)583-5500
City/Town Zip Code Telephone
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
Waste Management N.E.E.T., Inc. 25 Silver Street
Name of transporter Address
Portland, CT
City/Town
3. N/A
06480
Zip Code
Refuse transfer station and owner
(860)342-0667
Telephone
Address
City/Town Zip Code
4. Turnkey Recycling &environmental Enterprises
Final Disposal Site location name
97 Rochesterneck Road
Address
NH 03839
State Zip Corte
Telephone
Turnkey Recycling & Environmental
Enterprises
Gonic
City/Town
(603)330-0217
Telephone
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.
Grace Mitchell
Name
Office Manager
Position/Title
(413) 583-5500
Telephone
Ludlow, MA
City/Town
53cv
✓i/ & e_4/
rued Sign d e and Date
AccuTech Insulation &
Contracting, Inc.
100 State St., Bldg#119
Address
01056
Zip Code
Fee exempt(city,Town,district,municipal housing authority,owner-occupied residential of four units or less?) ®Yes ❑No
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