40 Asbestos Notification Form 2002 U Facility Dee ,ption
I Current or prior use of fagety:
KeT.S..i.oke...K.
2. Is the facility owner-oCcupied residential with 4 units or less? Z Yes 0 No
3. Facility Owner:
--DAILLE) e-e)ova_l.S 4o Ika.n 3t.
Name
Address
0 0 ascii-Am FTC)k.) MA . olOtpo 4/3 5-zei 52
Gay/Town
,w.
4 Facility's Owner's On-Site Manager
M/d4'e. P
Name
Cdyllowri
5 General Contractor —
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd.
Name
Address
Northfield MA. 01360 413 498-0201
ovrom,
Address
re/narrow
INJ code Telephone
Granite State Ins . Co.
contractors Workers Comp.Maurer Policy! Exp.Date
6 What is the size of the facility?....e0X4,0(so coc2 (/of floors)
0 Asbestos Transportation and Disposal
1. Transporter of asbestos-containing waste material from site to temporary storage site (if necessary)to final disposal silt
Shearer & Snide Inc. dba/Ace Asbestos 716 Pine Meadow Rd.
Name
Address
Northfield MA 01360 413 498-0201
City/Toxy
ZIP Code releplione
2. Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site:
Logan° TruckClPA14.,
Nam ing-waste Mgmt 209 Pickering Street
AM lien
Portland CT 06480
860-342-0667
Nate: Transfer
—.Q.1.6.......s.........■...................._ 47,fi rii 1 1p
Zip code Tereprione
WC8540584 09/01/01
IONS
ones
ompleted
ply with
ml of
II
fartalion
tt310CMR
king days
ion is
y abatement
the
of Labor
in
fquiremenls
5.12 den
silica/ion Is
'oject greater
N
kipuf al Form
oalth of
farts
Program
0017
IA 02112-
M may be
olhOng the
°medal
Acency Region
.os demodion/
topeations
NESHAPS de
Commonivealth of Massachusetts
Asbestos Notification Form — ANF-001
Asbestos Abatement DOSClipti011
1. Facility location:
tc-■3 C-Re_S krc(f2,1f_Cfr_
Male
.......... ........a`tfte \ C.N.
adman
baS.12—Ca-\Q,ArYt
WU is Oa ifiarbiloloaion?builifkig nom I.wing.ow mom
2. Is the facility occupied? Ales 0 No
3. Asbestos Contractor
Shearer & Sg4cle Inc dhafAce
Address
L-D Hanka(\
5at-i
owe
mm vvat A If-t S CIE alittn.)
Northfield MA .
CilKawn
AC000006
Lltarcena/
4. On-Site Project Supervisor/Foreman:
Ed Shearer/Tom Shearer
Mane
S. Project Monitor,
JT ..........
Name •
6. Asbestos Analytical Lab:
40L.g..PgNWint ,5A4-070/06
-i-fr s-n n.3G
NON
• 11000o WEALTH
s os • ine" Meadow Rd .
Address
01360 413 498-0201
?vox!. releptaxpe
Conitri bit(wntlan/arbal)
AS70245, AS70066
01.1
444 3(60,
01.1 Ce/Olicatien/
CerDficabon I
78112—P—C (Sat Sun
update
orner(uplain) beat
stem
7. Project startdate_ _/2:_7/02end datek./ P...4aPecif icworkhours(Mon.-Fri.)
s
&doe,
What e of project is this? (circle ens):
W
tapir reinvarionD
uttuLt» IIIWI
comply with the
Solid Waste
Division regula-
tions 310 CMS
18.00
Note:Contractor
must sign this
form for DLI
notification
purposes
3. Refuse transfer station and owner(ii applicable):
N/A
NAM
Address
City/rNm ho ode telephone
4 Final Disposal Site: k� RQC9�Ir
TV Yn
I(arMe,015 Waste Management/ Logano Truck
Osten Name exviv_erpf 6fs tuners Maine
ci n d_f 'Paf3tX -o6S
AddreSS 1-10o3-4330- oa Io
is in GoNlc. -PA �I-I 4-5-6-42-0N31 724 7-4.4 7446
D
Certification
The undersigned hereby states,under the penalties of penury.that he/she has read the Commonwealthot Massachusetts Regu
for the Removal.Containment or Encapsulation el Asbestos.453 CMR 6.00 and 310 CMR 715,and that the information conta
this notification is true and correct to the best of hisfnei knowledge and belief
Ethtard Tb3hectcw r y a bl4foi-
PAN Name MOWS!Signal use Dale
Shearer & Snide Inc. dba/
C Es bL _ Ace Asbestos Removal
413 498-
Nepreseolinp telepnmre
Northfield , MA. 01360
Position/ram
716 Pine Meadow Rd .
Aldrzas crynuwn lei nek
Fee exempt(City,Town,district,municipal housing authority.owner-occupied residential of tour units or less)?X yes
Sticker i(from front of form):
"15456 I
92.
9. Describe the asbestos abatement procedures to be used (circle): glove bag ercerore (9u cantina,n) anm
set—up variable air pressure,
exxvuaan duposai f omn(expaun poly work area ,HEPA vac,HEPA
filter respirator , wet asbestos
10. Is the job being conducted ft indoors O outdoors?
11. Total amount of each type of Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear ft.)/6,0 orather
surfaces(square ft.) n D to be removed, enclosed or encapsulated:
linear/square feet
boiler.breaching.dud,wa surface coatings... thermal solid care pipe insulation .J
c ouugaIedartlyweOpapupipelwblion... I(.0/ ewrlatngo en( —1
spray-on fireproofing dowel/spaywtwangs
cloths.wows Web tensile bond wall board
other(pleasedescribe)
12. Describe the decontamination system(s)to be used: 3 chamber decon unit w/warm water
shower,tyvek. suits ,HEPA 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 labeled double sealed poly bags
before removal from site .
14. For Emergency Asbestos Abatement Operations,the DEP and DLI officials who evaluated the emergency:
wanw d DEP artielar
Caw oIAUrroaaun
Nun o DU CIficial
ove of wrwaan
Title
Tire
Wuxi/
15. Do prevailing wage rates apply as per M.G.L.c. 149,§26,27,or 27A-F to this protect? ❑Yes ,No