169 Asbestos Notification Form 2003 Facility Description
1 Current or prior use of facility:
E DE)0( . . .. ..............
2. Is the facility owner-occupied residential with 4 units or less? Yes 0 No
3. Facility Owner:
50E? ?inane L.rn .. Eirn
sam, Address
Inge Tefeptfle .
caytrowffp
4 Faciftty's Owners On-Site Manager:
PiP
Name
Addre$5
Zepaxle Telephme
Co nilni4n
5. General Contractor:
Ace Asbestos Removal & Insulation 716 Pine Meadow Rd .
Marne Address
Northfield MA 01360 413 498-0201
ownim A'fifc aia.37a v Topton,
Granite State Ins. Co. WC-8-5.445-844- 09/01/0
yokyr
commearsivomemcompAnsumr Exp.Dare
6. What is the size of the facility? .c.1\c/o(sq ft) . .._-'(Sot floors)
Asbestos Transportation and Disposal
1. Transporter of asbestos-containing waste material from site to temporary storage site(it necessary)to final disposal site:
Ace Asbestos Removal & Insulation 716 Pine Meadow Rd .
Nam moray
Northfield, MA 01360 413-498-0201
Py/knov Zip Se Telephone
2. Transporter ot asbestos-containing waste material from removal/temporary storage site to final disposal site:
Waste Management of CT, Inc . 203 Pickering St.
Addlef 5
Name
Portland CT 06480 860-342-0667
Telephone
INSTRUCTIONS
1 All sections al(his
torn must be completed
In order to complySi
the Department of
Environmental
Protection notification
requirements c1310 CMR
7.15 (ten working days
prior ndit■alion Is
required of any abatement
prolee0:and to
Department of Labor
and Industries
notification regaremen6
of453CMR6.12 pen
days Prior notification rs
requited of ANY
abatement project gealet
than%tree Linear or
square/ee .
2 Submit Or iginal Earn
To
Commonwealth of
Massachusetts
Asbestos Program
P.01.120087
Baton,MA 02112-
0087
3 This form may De
used for notifying the
U S.Environmental
Protection Agency Region
of asbestos demolition/
renovation Or aliens
suolct to NESHAPS(40
CFR Subpart Ml.
Commonwealth of Massachusetts
Asbestos Notification Form — ANF-001
QAsbestos Abatement Description
1. Facility location:
Phaneuf reside/au
Name
Ciry/lown
) c, 9 1.)0(+1,,_ Ef„ St
Address
IC01(4ha.mpMn.....1. MA ot06,0
Zip cWe
b.asem.ent
Mu/is Ne mar ,IeIxaica?Milldam name.I.vim lie/.loon?
2. Is the facility occupied? 88 Yes ❑ No
3. Asbestos Contractor:
Ace Asbestos Removal & insulation 716
Name
Near t`:a.f i.e..1 c....MA
Ciy/TOwn
A0000006
IXI(irdltt/
q-/3 5$ 6- (c8c)
Telephone
Pine Meadow Rd .
AWress
01.54_
41 ? 40F-C2Q11
Zip ode relegvre
LA)r neon
Conlfal Toe(wnnenmrtal
4. On-Site Project Supervisor/Foreman:
Ed Shearer/Tom Shearer AS70245/AS7006e
Nam
5. Project Monitor:
Raymond.. J. Bresnahan
Nm
6. Asbestos Analytical Lab:
Environmental Sampling & Testing AA000132
oil Cenilioew,A
4M31604
IXI Cem1ioliaU
SEP - 4 2afr
Nam 00(thfirdtMl/
q 3 . Lit
7. Project shad date�/%/Qiend dateL/Lr0?sDedflc workhours(Mon.-Frl.)� a' Lit (Sat.Sun ) I"1 O
8e;!e-r ercuc.ked
8. What type of project is this? (circle one): demmmon laver haWYarr ' oilier rumam. heat
system
pda to
Note: Transfer Whim
Stations must 3. Refuse transfer station and owner(if applicable):
com
compy with the
Solid Waste N/A
Division repute- Name Address
lions 310 CMR
•
18.00
Note:Contractor
must sign This
form for DLI
notification
purposes
on/nn
4. Final Disposal Site:
Turnkey Recycling & Envir. Enterprises, Waste Mgmt of NH, Inc.
In rode Telephone
Lmuen Nane
97 Rochester Neck Rd .
timers Name
Address
Conic
Cin/Torm
NH--
03839 603-33.0-0217
fin code reepaene
D
Certification
The undersigned hereby states,under the penan,ies 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 irdormation contained in
this notification is true and correct to the best of his/her knowledge and belief.
Totaiized Starer
FMINene
wee
716 Pine Meadow Rd
Au Mswam
Ace Asbestos Removal
& Insulation
neeesnllry
413-498-0201
Telephone
Northfield, MA 01360
Address City/Town In coda
l
Fee exempt(City,Town,district,municipal housing authority,owner-occupied residential of four units or less)? yes ❑ no
Sticker / /I(from front of form): 77 /354/
?o eirnm:<uw
Fee.6192.
9. Describe the asbestos abatement procedures to be used (circle):
encapsulNbn diS,nsalonp orimaumaou
b b conducted indoors 7_outdoors?
gateW °scut' ull tonran,ren aenuo
set–up variable air pressure ,
poly work area ,HEPA vac,HEPA
filter respirator,wet asbestos
10. Is the jo eing O or other
11. Total amount of each type of Asbestos Containing Materials(ACM)
or e handled on
ntpiipes or ducts(linear ft.)J�_-
sudaces(square ft.) li ear/square feet
thermal,soed core pipe u¢ulalion..._ _J-
corrugateacbing,rS paper surface
ipeinsulatiings _ / wnsulating lemeni...
cpray-otdmWofing paper pipe insulation _J uoweVSgayer coatings
spray-on fireproofing — uareite board,wall board..cloths,woven fabrics _J
adn(please describe)12. Describe the decontamination system(s)to be used:
U FP Ab amber O d1 dec
c and unit Fit. t
water shower,. tyvel: suits , ..
13. Describe the itation/disposal methods to 0C MR 7.15 45e CMR ll
Hewet asbestos & r a m - in labelled double se ale d poly y 4ds
before removal from sire .
14. For Emergency Asbestos Abatement Operations.the DEP and DLI officials who evaluated the emergency.
Nam!
at DEP official
..__..._..__._.n
WedAUnpry>aan
Nan (Mal
Evieuoviumuaum....
15. Do prevailing wage rates apply as per M.G.L.c. 149,§26.27,or 27A.F to this project? ❑Yes No