48 Asbestos Notification Form 2003 isk
Commonwealth r Massachusetts
Asbestos Notification Form ANF-001
Sos
A. Asbestos Abatement Description
1. Facility Location.
Residential
Name of Facility
Northam ton,
Citylrown
Worksite Location:
MA
State
Basement, 15'and 2nd floor
Building name, m'
2. Is the facility occupied? 0 Yes ®No
3. Asbestos Contractor.
AccuTech Insulation &Contractn
Name
AS Ludlow, MA
city/Town
be AC000005
vder DOS License IS
on
of
on
'al
Please Enter Decal#
48 Old South Street
Street Address
01060 none
Zip Code Telephone
01056
Zip Code
Keith Jenkins
Facility Contact Person
Anthony Roy
4. Name of On-Site Supervisor/Foreman
To be determined
Name of Project Monitor
of Scilab
2 6. Name of Asbestos Analytical Lab
iginal
filth of
Us 7.
ogram
087
07/08/03
Project Start Date
7AM-4PM
Work hours Mon-Fri.
8. What type of project is this?
0 Demolition ® Renovation
• Repair 0 Other, please specify:
9. Check abatement procedures:
• Encapsulation
O Disposal only
• Other, specify:
Glove bag
O Enclosure
0 Cleanup
® Full containment
10. Is the job being conducted: ® Indoors? 0 Outdoors?
ECEIVEPI
JUN242003 IL
100 StateStreet''P°0°6$x F HEALTP
Address
(413)583-5500
Telephone
Contract Type:
Written O Verbal
President
Contact person's title
AS71233
DOS Certification#
DOS Certification#
M000162
DOS Certification#
07/11/03
End Date
N/A_
Work hours Sat-Sun.
Ion.doc-9/02
Asbestos Notification Form•Page 1 of 4
Commonwealtf f Massachusetts
Asbestos Notification Form ANF-001
go(300
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:
15
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
60
lin.ft sq.ft
lin.ft sq.ft
lin.ft sq.ft
lint ft sq.ft
15/
lin.ft sq.ft
68
other surfaces(square ft)
Insulating cement
Trowel/Sprayer coatings
Transite board,wall board
Other,please specify:
VAT
lin.ft sq.ft
lin.ft sq.ft
lin.ft sq.ft
/8
lin.ft sq.ft
12. Describe the decontamination system(s)to be used:
Basement-seal the criticals with 6 mil poly set up negative air remove the metal jacket from the boiler
and remove the air cell board,will need to clean and bag up misc. items.
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
dumb C itn
14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
N/A Title
Name of DEP official
Date of Authorization Waiver
N/A
Name of DOS official
Date of Authorization
15. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? ❑Yes E No
Waiver#
B. Facility Description
1. Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes E No
Cameron Coe 63 Prospect Hill Road
Address
Facility Facni Owner Name 03741 1603) 523-4390
Caoa an, NH Zip Code Telephone
City/Town
Same as above Address
4' Name of Facility Owner's On-Site Manager
Residential
City/Town
ion.doc•9/02
Zip Code Telephone
Asbestos Notification Form•Page 2 of 4
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310
Commonwealth _f Massachusetts
Asbestos Notification Form ANF-001
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Please Enter Decal 44
B. Facility Description (cont.)
N/A
5. Name of General Contractor
City/Town Zip Code
Granite State Insurance Company _
Contractor's Worker's Comp. Insurer
6. What is the size of this facility?
Address
Telephone
7252577 11/04/03
Policy Exp. Date
2000 2
Square Feet #of floors
C. Asbestos Transportation and Disposal
1. 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:
25 Silver Street
Waste Management N.E.E.T., Inc.
Name of transporter
06480 1860)342-0667
Portland, CT _
City/Town Zip Code Telephone
3. NIA Address
Refuse transfer station and owner
Address
City/Town Zip Code Telephone
4. Turnkey Recycling &environmental Enterprises Turnkey Recycling &environmental
Final Disposal Site location name Enterprises
97 Rochesterneck Road Gonic
Address City/Town
NH 03839 (603)330-0217
State Zip Code Telephone
actor
his form
itification
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.
Fee exempt(city,Town,district,municipal housing
ondoc•9/02
Analia St. George
Name
Administrative Assistant
Position/Title
(413)583-5500
Telephone
Ludlow, MA
City/Town
authority,owner-occupied residential
6-do -03
Authorized Signature and Date
AccuTech Insulation &
Contracting, Inc.
100 State St., Bldg#119
Address
01056
Zip Code
of four units or less?) ❑Yes ®No
Asbestos Notification Form•Page 3 of 4