91 Asbestos Notification Form 2003 fl Facility Description
1. Current or prior use of facility:
1Q, S1 EktE,
2. Is the facility owner-occupied residential with 4 units or less? Yes 0 No
3 Facility Owner.
cr(4-inco,A,Oion m( 0 lc(so stpo- 9 30 — "D-9 Z
. ..... .. .. ... . .. .
cdwro., to code lelephon e
4 Facility's Owner s On-Site Manager:
N))A
Mdrese
Lw wde
Selerftne
crioram,
5. General Contractor:
kce Asbestos ..Removal & Insulation 716 Fine MeadOw Rd .
Naf. Ade(.s..
Northfield MA 01360 413 498-0201
Ci Peiro An Ir a Cc a/a3 7a ce relsphone
Granite State Ins . Co. WE--9-5-40-5-84- 09/01/0
—_—_----
commartyworwscrynryonw AOACyl avast.
6. What is the size of the facility?&CC*(sq ft) ft of floors)
Asbestos Transportation and Disposal
1 Transporter of asbestos-containing waste material from site to temporary storage site Of necessary)to final disposal site:
Ace ASbestOs Removal & Insulation 716 Pine Meadow Rd .
Name Address
Northfield, MA 01360 413-498-0201
Cl /1 ' a,...4, wow,
2. Transporter ol asbestos-containing waste material from removal/temporary storage site to final disposal site:
Waste Management of CT, Inc . 203 Pickering St .
AMees
-DA-) nA F.7
pat
Commonwealth of Massachusetts
Asbestos Notification Form — ANF-001
13 Asbestos Abatement Description
Facility location
Co_II((IS esicien
Nana
l_coz r-1PZ MR
INSTRUCT la
1 All senors oILhs
form must be completed
m aoer to comply wan
Ihe Department of
Ern imnmenl al
Protection notilication
requlrments 01310 CMR
7.15 (tern working dap
brier nn✓icanon rs
/egWree at any abatement
Ord/ear.and We
Department of Labor
and Industries
notification equir amens
ol453CMR612 (ten
dap perm notification a
required al ANY
abatement Woteet y®ler
than dace kited or
spume led)
2. Slmme Or iQlnaI Form
To.
Commonwealth of
Massachusetts
Asbestos Program
P.D.B.120087
Boston,MA 02112-
0087
This lolm maY De
used E ne
C Se n mncaI
Agency
Region
or asoeslos demoltw
peno.our operations
NESHAPS
CFA Subpar(M1
City/town
73/senn4,1 t
Wlw tutee WWI/ bona t aldi ai mire.I.«mp.god rmn
2. Is the facility occupied? ;4 Yes Eli No
3 Asbestos Contractor'.
Ace Asbestos Removal a Tn
NMe
Nor.thf i.e1c._MA..
nomad
AC000006
DTI(anesI
4. On-She Project Supervisor/Foreman'
Ed Shearer/Tom _Shearer
Name
5. Project Monitor'.
RayxQnd...?.....Presnahan
None
6 Asbestos Analytical Lab'.
Environmental Sampling
Nan( 1117 03, yµ1/)
7. Protect start date___/ end datE Ts
q/ ko(zni
Address
O/oa0 a(00 -13c, c2 r2
Lm a x l e r e l e po n e
NOV 19 2003
Nr--HAMPTON EOARD OF HEALTH
lotion 716 Pine Meadow
AddeaT
0.1.1360
Zip rode
uJr
Corm ryre lwnNMeroaf)
41 ?— it? -
Telephone
A S70245/A S 70066
Oil Cenilicalu'r/
Pik'B1604
Ott CenuloliOI/
a Testing AA000132
8/o3 Oki cmniaaw/
3g- U
pacific work hours(Mon Fri.) a rISat.Sur. . /r-<
heat
B. What type of protean is this? (circle one)'. Dymond(
Note: Transfer
Stations must
comply with the
Solid Waste
Division regula-
tions 310 CMR
18.00
Note:Contractor
must sign this
form for DPI
iiotiication
purposes
Nene
Portland CT
wnnn»n
3. Refuse transfer station and owner Of applicable):
N/A
NaM
06480
do rub
Riede/if
Addtt11
LM1Ymmn by rale Telephone
4. Final Disposal Site:
Turnkey Recycling & Envir . Enterprises , Waste Mgmt of NH, Inc.
LOCI=Mn. Owners Name
97 Rochester Neck Rd .
conic
China
NH—
03839 603-33.0-0217
now. Telephone
D
Certification .
The undersigned hereby states.under the pena`les r.t ocriury.that he/she has read the Commonwealth of Massachusetts Regulations
for the Removak-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. Revised_ l o�l q'03
�}
rdu ard..._J e red m asro .._a Pere 9 (603 ._
Ace Asbestos Removal
cPRESID£ASE & Insulation 413-498-0201
............._...
hreseming (PIPpTNrc
IMO Nam
PoNid✓llne
716 Pine Meadow Rd
Address nfwIc m Zip rule
Fee exempt(City:Town.district.municipal housing authority,owner-occupied residential of tour units or less)?X yes O no
Northfield , MA 01360
Sticker I(from front of form): 717 SSG
as.m Lwle
Po'La WI:nor-We
Rev 6732
it con
9 Describe the asbestos abatement procedures to be used (circle)'. rayesu ec ure ivabl`F�'-i ' .Jts
ercdGdulaboo bispual onry o,ne,(upon') poly work area =
filter respire ^ t -
10. Is the lob being conducted X indoors X outdoors? O or amer
11. Total amount of each type of Asbestos Conttain�ing Materials eenACM)to
or eeandld on pipes or ducts(Iineat0 'i / 7
surfaces(square ft)____,123--to Imeausquare feel
FIRtefl9 ev 3o Iherma{soda rompipe imulalion J
Dorkr.al&o,nq.OW.Iper surface coatings —�— insuplmq arrenl.
sorruganll al layered paper pipe also/aeon /7J— ptrweij$ Yvcoalirgs _�=
clogs. fireproofing.. — tramile Dowd.wall Doa+d.
clots.woven Fabrics. _1—
Odle(plena descrlbe)- �—
Itobeused o cla amber d e con unit ` -
12. Describe the decontamination,lio ystemis, tuts PFPA vac for clean-uy
water shower, yve'�
?doh dr, labelled l 31 MB able sealed poi
-`
13. Describe the containerization/disposal
asbestos isposalmelhoi to l opened Cdou le sealed pci
Remet asbestos a r - - '_--
tram
before removal ye
14. For Emergency Asoestos Abatement Operations,the PEP and DLI officials who evaluated the erne
e
Name d Oft
Owed .....o_.._f._
noe ._...........
Anrrt d Ott Ulznl. -- -
02k rlaU'
15. Do prevailing wage rates apply as per M.G.L.c. 149. §2R.27.or nA-F to this project? � Yes X Nc