8 Asbestos Notification Form 2002 ctim
Fati/i6,Dose lion
1. Current or prior use of facility:
- Lease space
2. Is the facility owner-occupied residential With q units or
less?
❑Yes {� No
3. Facility Owner
Fred Grinnell
Northampton, MA
CIO/gown
If A9.n
PJ tdj Il •Owners On-Site Manager.
Webber
14 to°RAMP General Contractor.
N/A
wad
hem
01060
Z47code
562Kenne Road
(413) 586_,
Poplins
Colinvo
Merican Ch
Cp/IbdC(O/JWO/A9R pip NJ
Comp.insurer �— Telephone
6. What Is the size of the facllity73200 Poky/(sQ h)1(t of floors)
Asbestos Transportation and b sposal
I. Transporter of ashesms-containln
ns g waste material Gam site to temporary storage site(if necessary)
, Insulation g�� .
'.a_ 7m A O. to final disposal site:
Net- IP.
hpf
2 Transporter of asbestos-containing 0l
MM,,,,,,,,,,____ � Zbma ��_
Mop�-`"` n3rt N. g waste material from removaVtem Telephone
N.E.E.T.•.Ti-c rotary storage site to final disposal site:
APOrpss
Commonweal..of MassachusetttsNF 001
Asbestos Notification Form--
Asbestos Abatement Description
1. facility location:
p .
on
CMR
ays
Ianml
abor
amens
{Am
ahOn is
rfgreater
'ar
Address
Northampton
02t
• arygonn
Basement
the eotlsle Sion?br116i
a. Is me facility occupied? 0 Yes IgNo
3. Asbestos Contractor;
cc tiara& ---- $c
pal Vann
of
arts
rogmm
a$7
p92112-
01060
Zwrade
S North King King Street
(413) 556-0111
re.
� 5
may be
Allying the
onmenn
'Agency Region
ins demolition/
C
al license
4, On-Site Project Supervisor/Foreman:
1„.1.0019I-5:1_.at ez
Name
5. Project Monitor:
t
6. Asbestos Analytical Lab:
Name
-enddateJ2z
7, Project start date SJ�
t Sviceet Oe1ta Park
Address
Zips
Written
Coact Type "n( ImMeroa0
AS71103
l Cerlir�aiion1
IXICerolialinn7
-11 uric*/ONO Of HEALTW
(473) -5326
whops
ou ceeeiarm>' 81\H-4PM
02speciucwortrbours(Mon.Fr��i.l_�
°ro
tea'
. .,.,_a irircle one): demoldion
(S at.sun.)_
oW'ferohtn)
Hole:Transfer
Stations must
comply With the
Solid Waste
Division regula-
tions 310 CMS
18.00
Note:Contractor
must sign this
to for&I
notification
purpases
I Le.LraII,
Carno»p
3. Refuse transfer station and owner Of applicable):
WA
(F4f.1) '14.24Y-67
Telephone
Address
4. Final Disposal Site:
Stltleen AIIFgbanies Ia:1E1ll
4,co&
[EA Ghcta SanriraT_Trr
Loafing Mare GirasNmx
843 [Puller Pickirg Bred
A�zsr
tt,ihrtsrllaa, PA 154713 (814) 479-2537
rp ra Telephone
D
Certification
The undersigned hereby states,under the penalties of perjury,that he/she has read the Commonwealth of Massachusetts Re
for Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information coi
this notification is true and correct to the best of his/her knowledge and belief.
Aruba St. Gauge
rax Nana
/drurdstrative Assistait
Posilllk
0.j»t Street, tk1ta bark
Address
1/07/02
AwiwriredSiignaMZ ea&
Accdrech 7isulati[n&
fintnrtirg, Trr (413) 592-5326
/Npesminp Telephone
Qncopee, bM
fJMratm
01013
4'code
Fee exempt(City,Town,district,municipal housing authority,owner-occupied residential of four units or less)70 ye
Sticker i(from front of form): IS(Ott
9. Describe the asbestos abatement procedures to be used (chinks/airbag sago
aiapsulalron dµmsalaay
as
10. Is the job being conducted IN indoors 0 outdoors 7
11. Total amount of each type of Asbestos Containing Materials(ACM)to he handled on pipes or ducts(linear ft.) 6 or other
surfaces(squaw H.) to be removed,enclosed or encapsulated: d.
linear/square Teel
boiler,breaching duct,lank sralace coatings... / Memel,solid core pipe"aviation .
col lWaledw!awed paper pipe insulation....___/_____, rnsulafingcement _____/
spray-wr timproo(ng _J llsx
cloth/omen rabbis _/ bootie!burg well board
other(please describe _/
12. Describe the decontamination system(s)to be used:
Seal all cr it feels with 6 mil poly, pre—clean, lay drop cloth and remove
using the negative glove bag met nod.
13. Describe the containerization/disposal methods to comply with 310 CMR 7:15 and 453 CMR 6.14(2)(g):
ACM to be ale lzaRR i or wr rl in 6 mil ply ad&livered in a sealed cat{a1y
- e to thrp sate
14. For Emergency Asbestos Abatement Operations,the DEP and DLI officials who evaluated the emergency:
N/A
Mime dovo9idal nlle
Pm of Aeinma/lon
N/A
Waller/
Name a/DU Official Tdk
Date of ANbmvaemn Wailal
15. Do prevailing wage rates apply as per M.G.L.c.149,§26,27,or 27A-F to this project? ❑Yes Ni No