164 Asbestos Notification Form 2003 ErWcoWeseriptIon
1. Current or prior use of facility:
ggs 1 DEACE.
2. Is the facility owneroccupis residential with 4 units or less? V Yes 0 No
3. Facility Owner:
ck Yen I/pY riapLct
riosexkce_ Ma 0 106 2 4/3 - SFt "(ko Li
CoKom
Zr o man Telephone
4 Facility's Owners On-Site Manager:
Mann
Mtainz
Claygpol
11117)CrE !MAW!
5. General Contractor:
Ace_Asbestos....Removal & Insulation
Nam 716 Pine Meadow Rd
moms
Northfield MA 01360
orrow,
413 498-0201
474.1.0 0,42-170? Telephone
Granite State Ins . Co. W08410581 09/01/03
comixerswo*mcomgmsum pate/ &poem
6. What is the size of the facility?39)4.0(sq ft) -QC/of floors)
Asbestos Transportation and Disposal
1. Transporter of asbestos-containing waste material tram site to temporary storage site(it necessary)to final disposal site
Ace Asbestos Removal & Insulation 716 Pine Meadow Rd.
ware
morns
Northfield, MA 01360 413-498-0201
Cllyaram
Inane
TelePPone
2. Transporter of asbestos-containing waste material from removal/temporary storage site to fmal disposal site:
Waste Management of CT. Tnc.
Name 203 Pickering St.
Anis,
Portland CT 06480
Ogn nAn
;TIflS
s al this
completes
mplywie
lent et
bat
nonfu:ahon
in 310 CMR
arxrng pap'
than rs
ylyabafement
fuse
or of Labor
trier
emommeno
1614 pen
9olthration is
ANY
poled greater
liar or
Or'Tsai Form
wealth of
iunus
I Program
nor/
MA 01112-
aim may be
notilnnq use
lionmental
in
Agency Region
•,,s Csadome
on operations
n NFSHAPS(40
Commonwealth of Massachusetts
Asbestos Notification Form — ANF•001
Asbestos Abatement Description
1 Facility location.
rvet,fQ
r lore &en_
Narne
feslcliekct
).-A A
00wo
15,0, Se r-EVi
WWffIlieKMAIXOPOIMEftlgWrefoegryMW
2. Is the facility occupied? Yes _ No
3. Asbestos Contractor:
Ace Asbestos Femoval
Name
Nor.th`.ie.tc MA
A0000006
aercer /
4 On-Site Project Supervisor/Foreman'
Ed Shearer/TOr.F Stearet.
Nam
5. Project Monitor:
4aYF!and J . Presnatan
Name
6. Asbestos Analytical Lab. T Testing 9A0001 uZ – . ---
Environmental sampling _ ..
a¢amrriw/ 30
Nam ) '3 (Sat.Sun n C
.315/C�nddate 3/ °)ODecdlc workheurs(Mon-Fri update
7 Project start Date_ _—-- eat
orrwrrunuarr teat
system
An/1
1
No 765418; ,
tloy_ )4)1,0 YYk1QL St._
`413-5V v (o91lo
pine
9R2NOWE ,
RL)
FEB 2 I 2003
CC +0 Fw Dirt '
C Insulation 71.6 Pine alisaMP7O14 aOAnp,OF HFA{,pl
Address_.
plob'Z
Al.!
01.360__..
to top
wr;+4ee.
rmmv Fyfe(wnre veroal)
AS7024`/A570066
oucewlnnm/
31604..
c lLenrpaewd
wr,nt tvne of project is this? (cif Cie one)'.
repair
Note: Transfer
Stations must
comply with the
Solid Waste
Division regula-
tions 310 CAM
18.00
Note:Contractor
must sign thu
form for DU
notification
purpoSOS
wow.
3. Refuse transfer station and owner(if applicable):
N/A
Name
rifridOwn
&code
Address
by role Toren/me
4. Final Disposal Site:
Turnkey Recycling & Envir. Enterprises, Waste Mgmt of NH, Inc
(calm Nine brews Name
97 Rochester Neck Rd.
Addntss
Conic
ce,gme
Certification.
0 3 8 39 603-330-0217
twat& Telephone
The undersigned hereby states under the penalties of periury,That he/she has read the Commonwealth of Massachusetts Reg
for the Removal.Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information cont,
this notification is true and correct to the best of his/her knowledge and belief.
reekktrd
2) ,s/b0,treir 011
Ppm t, Aunion/Ed Sionaltue Dale
C ) Ace Asbestos Removal
TizEcsi & Insulation 413-498-0201
he
716 Pine Meadow Rd .
Altos
allY/Town
Fee exempt(City,Town.district,municipal housing authority,owner-occupied residential of four units or less)? yes
Sticker#(from front of form): 7 Co 5 1 1 I
liepresenOnv
Telephone
Northfield , MA 01360
lip axle
x.692.
9. Describe the asbestos abatement procedures to be used (circle)'. glove tag ercnmre II conranmruair A sure,
set—up varia
encapsulation omn ruMw^l poly work area , PEna vac , HEPA
filter respiretor , wet asbestos
10. Is the lob being conducted $indoors =outdoors?
11. Total amount of each type of Asbestos Containing MaxdenAoM)to be handled
d an pipes or ducts(linear tl.) 25 or ate
surfaces (square tt.) linear/square feet
Owlet.breaching.dud.rani surface coatings '_6P thermal solid core pipe eaularion
msubnng¢rrent_. —/-
saraugonfer4ofng pipe msmau°r _ troweVspayt rulings. _J
Oats.woven Woo — /_ (mast('boa a wall boar d. --
oltler( le woven eescnb
Other(please describe)
12. Describe the decontamination system(s)to be use 3 chamber decon unit '.g i t". ti:arm
Falter . shover , tyvek suits ,PEPA vac for clean—up .
13. Describe the containerization/disposal methods to comply with e310 CMR 7.15 and 453 sealed 6.14(2)(g). flags
3su:et atos � r _. -
before removal from site .
14. For Emergency Asbestos Abatement Operations.the DEP and DLI officials who evaluated the emergency.
Nam ol PEP°Maul
IMe
4a ml
Oak NNilWRAWI
Name d XI 01W21..
Ode aAutioad■on
15. Do prevailing wage rates apply as per M.G.L.c 149,§26, 27,or 27A-F to this project] ❑ Yes jy No