91 Asbestos Notification Form 2003 (2) Q facility Description
Current or prior use of facility:
RS l b EKC
2. Is the facility owner-occupied residential with 4 units or less? $'Yes 0 No
3 Facility Owner:
7& g
Ham'
Cow NS
P3crrk14.1Cty.4+ on M(}
Wear
4. Facility's Owners On-Site Manager:
fJ/A
9 ?
Adding
010(00
lip race
Mdren
81.0o- 93o - ga9g
Felp/rom
c,non bp woe TaleemMe
General Contractor:
Ace...Asbestos Removal t__Insu.lation 71.6,,,,pine..M.e.a.d.ow Rd .
Name Aidress
Northfield MA 01360 413 498-0201
117 0-/0 32G{[
Granite State Ins . Co. WC8540 584
•
Conhanora Workers Lamµlnswet potty'
6 What is the size of the facility?.30K$0.(sq ft) a- (I of floors)
Telephone
09/01/04
E.i .Deh
9 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
Actress
Northfield , MA 01360 413-498-0201
GbOani zip ca/e Telephone
Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site:
na ement of CT, Inc. 203 Pickering St .
Commonwealth of MassachusetaNF-001
Asbestos Notification Form =
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120887
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AsbestosAba iption
Facility location:
Co 0)03
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ne SIC al ci_,
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2 Is the facility occupied? X Yes _ No
3 Asbestos Contractor:
Ace Asbestos
Nem
Northfield f.r.A
cy/rown
Ac000006
Do License
4 on-Sile Project SuPery 1sorlForernan
Ere_.Shearer/TP.. wearer
Wine
t Monitor
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y no Ipng d,e
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Mon Agency Feg,or
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ti174
Name oo.I 32
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716 nape e
0.0r.t on Address
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Ids code
c rrJ ryle wnnennerevl
51 ' .9
relegn e
AS7024°/A$70060.
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estinq
,Na 10 11 403
,cmlrnwe
II�1� - . pecitic workhaurs(Mon-ki.)�
end care_--
7. Prolec)start dale_�� ,r
c7 Icircle one-
demo(lmr
Horne
Portland CT 06480
Note: Transfer cmna»n nr wle
Stations must Refuse transfer station and owner(if applicable).
comply with the
Solid Waste N/A
Division regula- NAM
Lions 310 CMR A°0nt
13.00
Note:Contractor
must sign this
form for 00
notification
purposes
re*OeM
Cirynoen fin ode Tef*e
4 Final Disposal Site:
Turnkey Recycling & Envir. Enterprises, Waste Mgmt of NH, In,
I aim fin Glows Nam
97 Rochester Neck Rd .
Amrzts
Conic
airy/Town
NH-
03839 603-330-0217
bp axle Te/ewmn
Certification
The undersigned hereby states,under the penalties of perjury,that he/she has read the Commonwealn ci Massachusetts Re
for IhsAemoraLContainment or Encapsulation of Asbestos.453 CMR 6.00 and 310 CMR 7.15.and that the information co:
this notification is true and correct to the best of his/her knowledge and belief. Reui Sect I C
Fnnl Mn
rdulara'.....L .Shearer
?R&S t Dpi
PotdkrV/Iee
716 P1-he Meadow Rd .
AWresz Cirynunl
Fee exempt(City;Town,district,municipal housing authority,owner-occupied residential of four units or less)?X yes
Sticker t(from front of farm): 7 7 I 3 Sc,
Cd'lil a/�
916/o3
AuNmvMSereNre Me
Ace Asbestos Removal
& Insulation 413-498-020
aeaesenenu telephone
Northfield, MA 01360
he aide
(circle): 4
set enclosure variable r,I
iPt uvlO rk dP used
9, Describethe asbestos abatement procedures to bee M i( pe1p
emapsWapun oiswsa'm11.
respire '
filter r e s U 1 r
10. Is the lob being conducted X indoors 1 outdoors?
Materials(ACM110 be handled on pipes or duds Ji
removed,enclosed or encapsulated-
linear/square opi .
1t sudateS sgtare It type olAsbestos Containing be em
Ober
sudaces(sguarett)�� �P1 eptaulalipn
yy inermal.sand rare p'0
Fliq Ia4N SUdace coalio95 � msu'alin9 aalrgs.
boiler rtugaiea rM�°`"' nsulaUae Uow'eUsg cem van sous
sprrogal�reproa�papd pipe oartilepaard.Ma or layer
dons.Woven ��
da116.wese escrib j deC or
�4 r '
12. Describe the decontamination system,$)to be used r
.k vac for clean_
t , ve - suits
WdtBT Sh o',J @T /
I with 310 GMR 715 and 45sealed MR btq '"g '
osal methods to comply 310 double
asbestos & r^[.,, in
13 Describe the eontamenzationl isp
4efo removal. frr, n �cte . evaluated e.e
r v Asbestos and DU officials who
1q, For Emergency psoestos Abatement Operations,the DEP
Tine
home duP urmi
.....__................
d wiwruam
rifle
wrrt d 011 pleat
Ndx�r
gale dwnoudm
Fto this Drglad7 �
r +es -
15. Do prevailing wage rates apply as her M.G:r c. 149.§26.27,or 27A
'Rev 6/92
or caret