185 Asbestos Notification Form 2003 CommonwealtC(Massachusetts
kiAsbestos Notification Form ANF-001
a
0
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.All sections of
this form must be
completed in order
to comply with
DEP notification
requirements of
310 CMR 7.15
and the Division
of Occupational
Safety(DOS)
notification
requirements of
453 CMR 6.12 6.
A. Asbestos Abatement Description
1. Facility Location:
Foote Residence
Name of Facility
Northampton
City/Town
Worksite Location:
Basement
185 South Street
772745
Please Enter Decal#
772745
MA
State
Street Address
01060 413-584-3379
Zip Code Telephone
Building name,#,wing,floor,room.
2. Is the facility occupied? ®Yes ❑ No
3. Asbestos Contractor:
AccuTech Insulation &Contracting,
4.
5.
2.Submit Original
Form to:
Commonwealth of
Massachusetts 7
Asbestos Program
PO Box 120087
Boston MA
02112-0087
Notification 9/02
ocT 2 A 2Cnn
100 State St., P.O. Box 376
Name
Ludlow, MA
City/Town
AC000005
DOS License#
Ellen Perrier
01056
Zip Code
Facility Contact Person
Brandon Besaw
Name of On-Site Supervisor/Foreman
To be determined
Address
(413) 583-5500
Telephone
Contract Type:
Homeowner
Contact person's title
AS70407
DOS Certification#
®Written ❑Verbal
Name of Project Monitor
To be determined
Name of Asbestos Analytical Lab
11/05/03
DOS Certification#
DOS Certification#
11/07/03
Project Start Date
8 AM to 4 PM
Work hours Mon-Fri.
8. What type of project is this?
❑Demolition
❑ Repair
® Renovation
❑ Other, please specify:
9. Check abatement procedures:
®Glove bag
❑Enclosure
❑Cleanup
• Full containment
10. Is the job being conducted
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
End Date
N/A
Work hours Sat-Sun.
® Indoors? ❑Outdoors?
Asbestos Notification Form•Page 1 of 4
Oa a
,t\ Commonwealth 2 Massachusetts
Lir Asbestos Notification Form ANF-001
Notification•9/02
772745
Please Enter Decal#
A. Asbestos Abatement Description (cont.)
11. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
365
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
/
lin.tt sq.ft
/
lin.fl sq.ft
lin.ft sq.ft
lin.ft sq.ft
365/
lin.ft sq.ft
other surfaces(square ft)
Insulating cement
Trowel/Sprayer coatings
Transite board,wall board
Other,please specify:
fin.ft
fin.ft
fin.ft
fin.ft
sq.ft
sq.ft
sq ft
sq.ft
12. Describe the decontamination system(s)to be used:
Two layers of 6 mil poly on the walls and floor with an attached 3 stage decon. unit. Seal criticals with
6 mil poly, pre-clean, lay drop cloth and remove using the negative pressure glovebag method.
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
rlllmn Rite.
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? ❑Yes ® No
B. Facility Description
1. Current or prior use of facility:
Residential
2. Is the facility owner-occupied residential with 4 units or less? ®Yes ❑No
Bob Foote 185 South Street
3.
4.
Facility Owner Name Address
Northampton 01060 413-584-3379
City/Town Zip Code Telephone
same as above
Name of Facility Owner's On-Site Manager
Address
City/Town
Zip Code Telephone
Asbestos Notification Form•Page 2 of 4
Commonwealth -. Massachusetts
Lif Asbestos Notification Form ANF-001
Amax
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
Note'.Contractor
must sign this form
for DOS notification
purposes
Notification•9/02
772745
Please Enter Decal#
B. Facility Description (cont.)
N/A
Name of General Contractor
6.
City/Town Zip Code
Granite State Insurance
Contractor's Workers Comp.Insurer
What is the size of this facility?
Address
Telephone
7252577
Policy#
3000
Square Feet
11/04/03
Exp.Date
3
#of floors
C. Asbestos Transportation and Disposal
Transporter of asbestos-containing material from site to temporary storage site Of 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.
Name of transporter
Portland, CT
City/Town
3. N/A
06480
25 Silver Street
(860)342-0667
Zip Code
Refuse transfer station and owner
Telephone
Address
City/Town Zip Code
4. Turnkey Recycling & Environmental Enterprise
Final Disposal Site location name
97 Rochester Neck Road
Address
NH 03839
State Zip Code
Telephone
Turnkey Recycling & Environmental Enterprise
Owner's Name
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
/O J.,ta-63
prized Signatu - a • Date
AccuTech Insulation &
Contracting, Inc.
100 State St, P.O. Box 376
Address
01056
Zip Code
Fee exempt(city,Town,district,municipal housing authority,owner-occupied residential of four units or less?) ®Yes ❑ No
Asbestos Notification Form•Page 3 of 4
Commonwealth _r Massachusetts
177a 7V&
Please Enter Decal#
Asbestos Notification Form ANF-001
772742
A. Asbestos Abatement Description
nportant:
then filling out 1.
wins on the
omputer,use
my the tab key
move your
ursor-do not
se the return
ISTRUCTIONS
.All sections of
Ys form must be
ompleted in order
a comply with
)EP notification
equirements of
110 CMR 7.15
lnd the Division
if Occupational
Safety(DOS)
lotification
equirements of
153 CMR 6.12 6.
Facility Location:
Foote Residence
Name of Facility
Northampton
City/Town
185 South Street
VVorksite Location:
Basement
Building name,#,wing,floor,room.
2. Is the facility occupied? ®Yes
MA
State
Street Address
01060 413-584-3379
Zip Code Telephone
❑ No
3. Asbestos Contractor:
AccuTech Insulation & Contracting,
4.
5.
?. Submit Original
:arm to:
3ommanwealth of
dassachusetts 7.
ksbestos Program
'O Box 120087
3oston MA
)2112-0087
Notification•9/02
OCT ? � y,,... _.
100 State St., P.O. Box 376
Name
Ludlow, MA
City/Town
AC000005
DOS License#
Ellen Perrier
01056
Zip Code
Facility Contact Person
Brandon Besaw
Address
(413)583-5500
Name of On-Site Supervisor/Foreman
To be determined
Telephone
Contract Type: ®Written ❑ Verbal
Homeowner
Contact person's title
AS70407
DOS Certification#
Name of Project Monitor
To be determined
DOS Certification#
Name of Asbestos Analytical Lab
10/21/03
Project Start Date
8 AM to 4 PM
DOS Certification#
10/23/03
End Date
N/A
Work hours Mon-Fri•
8. What type of project is this?
❑ Demolition
❑ Repair
Z Renovation
❑Other, please specify:
9. Check abatement procedures:
Z Glove bag
❑ Enclosure
❑Cleanup
® Full containment
10. Is the job being conducted:
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
Work hours Sat-Sun.
® Indoors? ❑Outdoors?
Asbestos Notification Form•Page 1 of 4
. \ Commonwealth _r Massachusetts
kj Asbestos Notification Form ANF-001
Notification•9/02
Please Enter Decal#l "
A. Asbestos Abatement Description (cont.)
11. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
515
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
/45
lin.ft sq.ft
lin.ft sq.ft
/
lin.ft sq.ft
lin.ft sq.ft
515/
tin.ft sq.ft
45
other surfaces(square ft)
Insulating cement
Trowel/Sprayer coatings
Transite board,wall board
Other,please specify:
1n.ft
lin.ft
/
sq.ft
sq.ft
sq.ft
/
fin.ft sq.ft
12. Describe the decontamination system(s)to be used:
Two layers of 6 mil ploy on the walls with an attached 3 stage decon unit Seal criticals with 6 mil poly
pre-clean lay drop cloth and remove using the negative pressure glovebag method.
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
dnrnn cite
14. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
Bob Weinburg
Name of DEP official
10/17/03
Date of Authorization
Title
W237-03
Waiver#
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? ❑Yes ® No
B. Facility Description
1. Current or prior use of facility
Residential
2. Is the facility owner-occupied residential with 4 units
Bob Foote
Fadlity Owner Name
Northampton 01060
City/Town Zip Code
same as above
3.
4.
Name of Fadlity Owner's On-Site Manager
or less?
Z Yes ❑ No
185 South Street
Address
413-584-3379
Telephone
Address
CitylTown Zip Code
Telephone
Asbestos Notification Form•Page 2 of 4
Commonwealth _r Massachusetts
- 1 Asbestos Notification Form ANF-001
Tote:Transfer
tations must
omply with the
olid Waste
Iegultegul n
ations 310
MR 19.000
Please Enter Decal)0\
B. Facility Description (cont.)
5.
N/A
Name of General Contractor
Address
City/Town Zip Code
Granite State Insurance
Contractor's Worker's Comp.Insurer
6. What is the size of this facility?
Telephone
7252577
Policy#
3000
Square Feet
11/04/03
Exp. Date
3
#of floors
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:
Vote:Contractor
rust sign this form
Or DOS notification
purposes
Notification•9102
Waste Management N.E.E.T., Inc. 25 Silver Street
Name of transporter
Portland, CT 06480 (860)342-0667
City/Town Zip Code Telephone
3. N/A
Refuse transfer station and owner Address
City/Town Zip Code Telephone
4. Turnkey Recycling & Environmental Enterprise Turnkey Recycling & Environmental Enterprise
Final Disposal Site location name Owner's Name
97 Rochester Neck Road
Address
NH 03839
State
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.
Zip Code
Gonic
City/Town
(603)330-0217
Telephone
,O-ce-03
Grace Mitchell
Name
Office Manager
Position/Title
(413)583-5500
Telephone
Ludlow, MA
City/Town
orized Signal - - • •ate
AccuTech Insulation &
Contracting, Inc.
100 State St, P.O. Box 376
Address
01056
Zip Code
Fee exempt(city,Town,district,municipal housing authority,owner-occupied residential of four units or less?) ®Yes ❑No
Asbestos Notification Form•Page 3 of 4