14 Asbestos Notification Form 2002 Foci/ityyscripiion
Current or odor use of facility:
Residential
2. Is the facility owner-occupied residential with 4 units or less? tli Yes 0 No
3. Facility Owner:
Laverne Kerr
gyre
Northampton, MA
14 Columbus Avenue
CoVrosu
Address
01060 (413) 584-5897
Crypown
Lpa& TJKNrvIe
4. Facility's Owner's 0n-Site Manage
i7 'I "{t ^game as above
a I TX Gyro
Address
5. General Contractor:
N/A
Name
Address
Zip code
TekpAan•
Mericar Zrirh [,C-37 '189-02 11/W/02 •
Conharlars Workers Comp.Insurer Pain &ADffie
6. That Is the size of the facility? 3000 (sq fl) 2 (i of floors)
Ei Asbestos Transportation and Disposal
1. Transporter of asbestos-canlalning waste material from site to temporary storage site(if necessary)to final disposal site:
kaflah Insulation&Cmtr. T,_ ha
Iljnr Sh 1bl t„ 11adr
Nona hales
aiarq ', Ml 01013 (413) 597-5726
City/7own Zna b Telephone
2. Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site:
Waste I"negated: MEET r Irc. 25 Silver Street
AA1reu
1_1ttiaii, Cr - r-1.Ari
Rrn\ fl... ...��
:none
s al leis
completed . Cay/rc,,
mini Basement
nit of
tai • NOalbtlre xmbik tar, nl beildbprnmq 1,,
9ilication
if310CM11
Ping days
on is 3. Asbestos Contractor:
xadale ea
of tabor
BY /r���
luIremenls Q'tiCQ P, ply 01013
12 (tea
Vite ,is
lr 113000305
leCtrealer IXWbce'ru/
va
Commonwealth ulMassachusetts
Asbestos Notification Form— A NF-00 i
NQ 762461
I
Asbestos Abatement Description �
1. Facility location:
Kerr Residence
14 Columbus Avenue
Hanle
Northampton, MA
01060
(413) 584-5897
2. Is the facility occupied? ®Yes 0 No
OCT 18Ile
Lc 11ypt
a mall 7 6Utat-la1&Q rU lit Dm* Stree t, thlta Park NL P.THAMPlON BOARD OF NFALIN
Name Add=
arm z®code
Written
(413) 592-5376
rote one
Co„mn ripe l"rtrervtsez0
4. On-Site Project Supervisor/Foreman:
eralFOim Dorey Besaw AS71928
Name LYICe,brnzliun/
lth of
fts 5. Project Monitor:
gram/ N/A
12112. iltene
ay be
np the
mlal
vcy Region
volition/
zaans
hPP6(4O
I).
6. Asbestos Analytical Lab:
N/A
PLICeZYcaffon/
aicewcabon1
7. Pmjectstartdate 1031102enddate10(31i OZspeciiicworkhours(Mon-Fri) 8AM-4PM (SatSun.)
8. What type of project is this? (circle one): dmwbiion ,gar rewmliar % nther/eglen/
eemc:'Tans/et. akTon &ode re*oee
with I he
Stations must 3. Refuse transfer station and owner(if applicable):
campy
Solid Waste N/A
Division mph- • , ,dyes,.
lions 310 CMR
18.00
Nate:Contractor
must sign this
form for DLI
notification
purposes
CllpTowm 4,rode re/e�me _
4. Final Disposal Site:
Smithy n e* +m s Landfill W_[tsta Sel cerl r..-
LaaGV'/6ne an=Naar
843 1111er Picldcg Wei
Address
C»Ticisvile, PA
n
1 Va7A (814) 479-2517
zip cak Tekp1me
D
Ce tfflcat%n
The undersigned hereby states,under the penalties of perjury,that he/she has read the Commonwealth of Massachusetts Regula
for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the Information contain
this notification is true and correct to the best of his/her knowledge and belief.
Gloria Jenkins
Print Name
V. President
nasilimlen
Depot Street, Delta Park
AWhorI dS'gsahee/
me FtOCAQFrh 'c
10/16/02
b
Lion&
Crntnrti m_ hr __— (413) �-5
sou hkpMne
Chicopee, VA 01013
Address
Worn Seto*
Fee exempt(City,Town,district,municipal housing authority,owner-occupied residential of four units or less)7¢11 yes ❑
Sticker 8(from front of form): 74v1.4 I
9. Describe the asbestos abatement procedures to be used (cireld: nM'teda,,,,, efle„eh„e y
wMbpswaldar it saIat driwlegdln)
10. is the job being conducted C4 indoors D outdoors?
11. Total amount of each type of Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear ft) 154 or other
surfaces(square ft.) 0 to be removed,enclosed orencapsulated: - t,
//near/square teat
boiler,.Aching dg lanksuAcoatings / Mean*solid corn pipefasola/¢n...... 154/
combated or&yamd paper imbeinsulation.... / budding cement •spraton5pmofing ___/____ Imwf/spayercoalaws _I
c h woren/bad _/ flanswba,4 wall board _/J
other(please desalbe,) _1_ _
12. Describe the decontamination system(s)to be used: •
Seal criticals with 6 mil poly( pre—clean; 1 a drop rlorh and
remove using negative prepcure glnvebag merhnd
13. Describe the conlainerizafmddisposal methods to comply with 310 CMR 7:15 and 453 CMR 6.14(2)(g):
fi a t t o b e(h itilp •-x-. o r , p.. in 6 mil poly ad delivered in a sealed=paw
alMA'a to . . site.
14. For Emergency Asbestos Abatement Operations,the DEP and DLI officials who evaluated the emergehcy:
A&,w o/DEPOilidd
Vale of Autheinnlon
Waiiv/
Name°Intl mod
!db
Oak of Authorize= (Nand/
15. Do prevailing wage rates apply as per M.G.L.c. 149,§26,27,or 27A-F to this project? D Yes Of No