91 Asbestos Notification Form 2003 (3) 1377;5--y Description
1. Current or prior use of facility:
gsf of
2. Is the facility owner-occupied residential with 4 units or less? Si Yes C No
3. Facility Owner:
}7Fh11�
Name
apt-Li NS
1;.3ot Ftgr +jan mPc
ainnom
4. Facility's Owners On-She Manager:
0)A
Marne
Cmnani
5. General Contractor:
Ace..AShestas.....R.emoval_6._Insulation 716-.P.ine..-Meadow Rd -
Nme 01360 413 498-0201
Northfield MA reb3
LlGr a ZiP[eCS3C$�} -G u
09/01/04
Granite State Ins . Co. Exp,pate
Contractors Workers Comp.Insurer. Porky/
6. What is the size of the facility? St%(s4 ft) a- (0 of floors)
9 ( Nom+
Address
ploCoo %to0- 930 - Ea-9z
tip We Rleplron
Address
lip wde Telephone
ElAsbestos Transportation and Disposal
1. Transporter of asbestos-containing waste material from site to temporary storage site(if necessary)to final disposal site:
Ace Asbestos Removal & Insulation 716 Pine Meadow Rd .
Name Address
01360 413-498-0201
013
Northfield, MA rNwepnu
Cif/IOW1 zi:code
2. Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site:
waste Management of CT, Inc. 203 Pickering St .
AM z
Portland
Amrresx
CT 06480 _ 860---342-0667
TaWWW
Csh
Commonwealth of Massachusetts
Asbestos Notification Form — ANF•001
Asbestos Abatement Description
1. Facility location: ,l
-(10 Niels Name
A.torcHsc iTh c) ILO
nsenien L
IX STRIJ CT IC
All senors of IhI
Ng must be completed
ow to comply with
e Department al
mironmenlel
roleetian notification
guiremeras of 310 CMR
IS (ten workmq days
'ior notification is
puffed of any abatement
oleo):and the
eparlment of Labor
nd Industries
alifkalion requirements
953 CMR 6.12 (ten
ays prof nolilicaNm is
gored of ANY
farement gOleo!91 ealer
an here Sear of
pare Ire)
SWDmi1 Original Pam
ommomaaalth of
lassachuselts
sbestos Program
AS.120087
ostoo,MA 02112-
087
This tom may be
sad for notifpng the
S.EnvironmentaI
roteaon Agency Region
of asbestos demolition/
ration operations
ubjed to NESHAPS(40
FR Subpart Ml.
City/form
IN)al IS IntMlhne ft4nl9,uiltlg name I wing,fluor room
2. Is the facility occupied? X Yes 11 No
91 /k2�ki
Address
0/06 0
Ip
3. Asbestos Contractor:
Ace Asbestos Removal Insulation 716 P
Name
8160-930 -EYB
Telephone
ne Meadow Pd .
Address
tier.thf i.e_lc MA._ 0.1150
Zip rode
ON/lom
A0000006
IXILimse/
4. On-Site Project Supervisor/Foreman
Ed ShearerfTom Shearer
Name
5. Project Monitor.
Ray=nd_..7• Bresnahan
Name
Jri
Court Type(wmeurntll)
oL
41x-<4P-PLQ1
Telephone
j .t i SEP 17 2003
;570245/AS7006 �,_�_—_
I cvliliGAW/
N"-"HAMPTON BOARD OF HEALTH
AM31604
aI CemnauaiI
6. Asbestos Analytical Lab:
Environmental Sampling S Testing AA000132
Name 00 RMIairno/
7. Project startdatel°/0/03end bate 13/ai/D3 spec(ic workhours(Mon-Fri.)
8, What type of project is this? (circle one):
demotilion
835 V (satSun.) ,
update
e'er e,pra.,r .eat
Sv Stet
Cre'pYNwn�J
Note: Transfer
Stations must
comply with the
Solid Waste
Division regula-
tions 310 CMR
18.00
Note:Contractor
must sign this
form for DLI
notification
purposes
up/A46
3. Refuse transfer station and owner(if applicable):
N/A ..
Name
curator
4. Final Disposal Site:
Turnkey Recycling & Envir . Enterprises, Waste Mgmt of NH, Inc.
Lalm Nine Owners Mn
97 Rochester Neck Rd .
Address
tip ule releltone
Adorns
Gonic
CirAtm
NH-
03839 603-33.0-0217
Zit axle Telephone
D
Certification
The undersigned hereby stales,under the penattles of perjury,that he/she has read the Commonwealth of Massachusetts Regulatio
for the-Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15.and that the information contained
this notification is true and correct to the best of his/her knowledge and belief.
f=dulard >.Sbearcr
Pm(Nang
SS tIa£hE
voweamte
716 Pi-he Meadow Rdzi arse
A6fms wow
Fee exempt(City,Town.district,municipal housing authority,owner-occupied residential of four units or less)?P6 yes ❑ n
tycrupo 9/i6/03
Auarot&Shgeleee On
Ace Asbestos Removal
& Insulation 413-498-0201
Repesenfln4 Telephone
Northfield , MA 01360
Sticker i(from front of form): 71713 a,
>aimmy o"y
Moms,
esicme
emdicomesiMpoi
mscn Lae
Rev.692
9. Describe the asbestos abatement procedures to be used (circle)'. grove w enclosure Oil coma"V mew
set—up variable air pressure ,
enrapseufUf dispomIpmy omer(expoint
poly work area , HEPA vac HEPA
,
filter respirator,wet asbestos
10. Is the job being conducted X indoors E outdoors?
11. Total amount of each type of Asbestos Containing b
e removed,Materials or
(ACM)te handled on
ntpippes or ducts(linear ft.) / 70 or other
surfaces(square ft.) 30
linear/square feet
FIrEaThu7
¢�N thermal,sold rare pipeirsulation _S_
Dotkr,brew ug.layered k pipe insulation corrugated or layered per pipe insulation /r%47/ insulating cement_ —�
spraran brem°fog_ - UW818 troveYspiayer
bcfl coatings _l
cloths,,woken fabrics. Mile bawd,wall board _J
of a(please describe).....
12. Describe the decontamination system(s)to be used'. 3 chamber decon unit wi t,in warm
water shower, tyve'. suits , FEPk vac for clean—up.
13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g).
Rewet asbestos & pack in labelled double sealed poly 'h
before removal from site .
14. For Emergency Asbestos Abatement Operations,the DEP and DU officials Who evaluated the erne'gency
NOS ems/Onkut
mteenerteuxo,
Nene co I Ott Mow
rive
rarer
rime
15. Do prevailing wage rates apply as per M.G.L.c. 149,§26, 27,or 27A-F to this project? II Yes No