811 Project Revision Notifications & Asbestos Notification Forms 2008 n
mportant:
'Men filling out
ones on the
:omputer,use
fly the tab key
o move your
:ursor-do not
we the return
fey.
NSTRUCTIONS
I. This form is
tnly available far
online filing of
umject date
evisions
?. Enter project
Jena(number.
3. Validate that
he project
°cation is correct
for the entered
decal.
0. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
Massachusetts Department of Environmental Protection ':100079172
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
811 NORTH KING STREET
2.Street Address _
NORTHAMPTON J [MA
3 City 4.State
4135820523
6.Telephone Number
L
n
J S.Zip Code
B. Project Cancelled
Check here if this project is/was cancelled.
C. Project Dates
L12/03/2008
1.original Start Date(mMdd(yyyy)
12/22/2008
3-Latest Revised Start Date(mmfddlyyyy)
12/12/2008
2.Original End Date tmmfdd/yvvvl
12/31/2006
O.Latest Revised End Date(mm/ddlyyyy)
D. Revised Project Dates
F2,18/2008
1.Revised Start Date(mmlddlyyyy)
2 Revised End Date Date(mMddlyyyy)
E. Other Project Revisions
F. Revision History
EDEP: 12/03/2008 08:18:04 AM
EDEP: 12/12/2008 03:28:18 PM
anfO6pdrndoc•rev.215/04
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
Decal Number
G. 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 600 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.
HEATHER R. CREPEAU j
1. Name
OFFICE MANAGER
2. Position/Title
ACCUTECH
4 Representing
100 STATE STREET
6. Address
LUDLOW
7. City/Town
ant66pdm.doc•rev.2/5/04
Authorized Sin
12/18/2008
3. Date(mm/dd/WW)
`413)583-5500
5. Telephone
101056
8 Zip Code
Important:
When filling out
yorms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention—Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079172
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
811 NORTH KING STREET
2 Street Address
NORTHAMPTON
3.City
4135820523
6.Telephone Number
aX
MA
ate
5.Zip Code
INSTRUCTIONS
1. This fans is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes
B. Project Cancelled
I I
Check here if this project is/was cancelled.
C. Project Dates
12/03/2008
1.Original Start Date(mm/dd/y)y)
12/15/2008
3.Latest Revised Start Date(mm/dd/yyyy)
12/12/2008
2.Original End Date(mm/dd/yyyy)
12/24/2008
4 Latest Revised End Date(mmldd/wyy)
D. Revised Project Dates
12/22/2008 x2/31/2008
1.Revised Start Date(mm/dd/yyyy) 2.Revised End Date Date(mnVdd/yyyy)
E. Other Project Revisions
F. Revision History
EDEP: 12/03/2008 08:18:04 AM
anfo6pdrneoc•rev.2/5/04
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
(100079172
Decal Number
G. 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 715,and that the information contained in this notification is true and correct to the best of his/her knowledge
and belief.
HEATHER R.CREPEAU I /
1. Name Authorized Sienat re
OFFICE MANAGER j 82/12/2008
2. Position/Tltle 3. Date(mm/dd/Wrvl
■ACCUTECH INSULATION 8 CONTRACTING 1(413)5.83-5500
4 Re resenting 5 Tele hone
_.._ p-
100 STATE STREET
6. Address - '
.LUDLOW 1 .
City/Town 8 e. Zip Zip
] Ci Code
anfo6pdrn doe•rev.2/5/04
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct 1.Original Start Date(mmidd/w rv)
for the entered
decal
3 Latest Revised Start Date(mm/dd/yyyy)
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100081952
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
1811 NORTH KING STREET
2.Street Address
!NORTHAMPTON
3.City
4135820523
6 Telephone Number
MA
4 State
5.➢p Code
B. Project Cancelled
Check here if this project is/was cancelled.
C. Project Dates
12/12/2008
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
12/17/2008
2 Original End Date(mmldd vWv)
4.Latest Revised End Date(mm/dd/yyyy)
D. Revised Project Dates
1.Revised Start Date(mm/tld/yvyy)
12/15/2008
2.Revised End Date Date(mmrdtlryyyy)
E. Other Project Revisions
F. Revision History
anfO6pdm.doc•rev.215/94
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100081952
Decal Number
G. 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.
HEATHER R. CREPEAU
I Name
OFFICE MANAGER
2. Position/Title
ACCUTECH INSULATION &CONTRACTING
4 Representing
1100 STATE STREET
6. Address
uthorized Signet
12/15/2008
3. Date(mm/dd/ww)
-01
(413)583-5500
5 Telephone
LUDLOW
7. City/Town
an(O6pdmdoc•rev.2/5/04
01056
8 Zip Code
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key
a
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079176
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
811 NORTH KING STREET
2.Street Address
NORTHAMPTON
3.City
4135820523
6.Telephone Number
MA
4.State
5 Zip Code
B. Project Cancelled
Check here if this project is/was cancelled.
C. Project Dates
12/18/2008
I.Original Start Date(mm/dd/yyyy)
3.Latest Revised Start Date(mMdd/yyyy)
12/30/2008
2.Original End Date(mMdd/vvw)
4.Latest Revised End Date(mm/dd/ytyy)
D. Revised Project Dates
01/08/2009
1
Revised Start Date(mm/dd/yyyy)
01/16/2009
2.Revised End Date Date(mn ddtyyyy)
E. Other Project Revisions
F. Revision History
1�1 6 C F I 1/ G
DEC 1 6 2008 U!
NORTHAMPTON BOARD OF HEALTH
anfO6pdm.doc•rev.2/5/04
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention—Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079176
Decal Number
G. 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.
HEATHER R. CREPEAU
1. Name
OFFICE MANAGER
2. Position/Title
ACCUTECH INSULATION &CONTRACTING
4. Representing
12/15/2008
3. Dale/mm/dd/wwl
(413)583-5500
5. Telephone
100 STATE STREET
6. Address
LUDLOW
7 City/Town
anfo6pdm.doe•rev.2/5/04
01056
8. Zip Code
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certify your
notification_
Submit date
changes
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079172
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
811 NORTH KING STREET
2.Street Address
NORTHAMPTON
3 City
4135820523
6.Telephone Number
A
4 State
5 Zip Code
B. Project Cancelled
Check here if this project is/was cancelled.
C. Project Dates
12/03/2008
1.Original Start Date(mm/dd/yyyy)
3.Latest Revised Start Date(mm/dd/yyyy)
12/12/2008
2.Original End Date(mMdd/yyyy)
4.Latest Revised End Date(mm/dd/yyyy)
D. Revised Project Dates
12/15/2008
1.Revised Start Date(mm/dd/yyyy)
12/24/2008
2.Revised End Date Date(mSddlyyyy)
E. Other Project Revisions
F. Revision History
anfO6pdm doc•rev.2/5/04
I ` '
r
mportant:
NTen filling out
forms on to
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100081952
Decal Number
A. Asbestos Abatement Description
1. a Is this facility fee exempt-city,town, district, municipal housing authority,owner-occupied
residence of four units or less? D Yes ❑No
b.Provide blanket decal number if applicable:
2. Facility Location:
INSTRUCTIONS
1 MI sections of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310 5
CMR 715
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 6 12
MASSACHUSETTS HIGHWAY DEPARTMENT
a.Name of Fad'
NORTHAMPTON
c.cityfrown
3. Worksite Location:
0
0
ROOM 212
a Building Name/Bu•Iding Location
MA
d Stale
ii
Blanket Decal Number
811 NORTH KING STREET
b.Street Address
01060 (413)582-0523
e.Zip Code
b.Building ii c Wing
Is the facility occupied? n Yes ❑No
Asbestos Contractor.
ACCUTECH INSULATION &CONTRACTING I
a.Name 01056
LUDLOW
c. it /tow
AC000005
f.DOS License Number
c
n
b_Fadlit Contact Person
6 BRANDON E BESAW
a.Name of On-Site S p rvsoriForeman
URS
7. a.Name of Project Monitor __ —i
URS
Name of Asbestos Anal el Lab
12/12/2008
Z
d
•
Code
8.
9.
a.Pro'ect Start Dat
7:00-5:00
c.Work hours Man-Fri.
O 10. a That type of project is this?
o fl Demolition 1 Renovation
Repair ❑Other, please specify:
11. a. Check abatement procedures:
O ❑Glove bag ❑ Encapsulation
o ❑ Enclosure i_i Disposal only
❑Cleanup ❑Other,specify:
Full containment
12. Is the job being conducted: IJj Indoors? ❑Outdoor ?
mtdd
11
z
C
f.Telephone Number
d.Floor e Room
100 STATE STREET
b.Address
4135835500
e.Telephone Number
g. Contract Type: 0 Written ❑Verbal
i Contact Person Title
AS070407
b.Su•ervisorfForeman DOS Certification Number
AM061710
p Pro ed Monitor DOS Certification Number
AA000175
b Asbestos Ana! tical Lab DOS Certification Nu:
12/17/2008
b.End Date mmldd
N/A
d.Work hours Sat-Sun.
• anf001ap doc•10102
Asbestos Notification Form•Page 1 of 3 II
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100081952
Decal Number
A. Asbestos Abatement Description (cant.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or
encapsulated:
0
50
a.Total pipes or ducts(linear X) b. total other surfaces(square X)
c.Boiler,breaching,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
I.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
Lin.ft
Lin.X.
Sq.X.
Sq.ft
ft.
Lin.fl. Sq.X. I.Specify
d.Insulating cement
f.Trowel/Sprayer coatings
h.Transite board,wall board
1.Other,please specify:
14. Describe the decontamination system(s)to be used:
Lin f1
S•11 fl
Sq.ft.
SEAL CRITICALS WI 6MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNIT&INSTALL AIR
15. 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
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
1N/A
a.Name of DEP Official
c Date(mmlddlyyyy)of Authorization
N/A
e Name of DDS DRdal
b.Title
d.DEP Waiver#
DOS Official Title
g.Dale;• m/dd/yyyy)of Authorization
h.DOS Waiver#
17. Do prevailing wage rates as per M.G.L.c. 149, §26,27 or 27A—F apply to this project?I71 Yes❑No
° B. Facility Description
1 Current or prior use of facility
OFFICE SPACE
2 Is the facility owner-occupied residential with 4 units or less?
3
MASSACHUSETTS HIGHWAY DEPARTMEN
a Facility Owner Name
° NORTHAMPTON
o c.City/Town
4 'KRISTEN WELLS
a.Name of Facility Owners On-Site Manager
2
01060
d Zip Code
anf00lap doc-10/02
c.City/Town
❑Yes
No
811 NORTH KING STREET
b.Address
1413-582-0523
e.Telephone Number(area code and extension)
b.On-Site Manager Addre
413-743-3065
d.Zip Code e Telephone Number(area code and extension)
Asbestos Notification Form•Pa e
mi
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
B. Facility Description (cont.)
BURKE CONSTRUCTION
5.
Note.Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
COMMERCE B.INDUSTRY
surer
C Contradofs Worker's Comp-
{ the size of this facility?
1. Transporter Transportation
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
ACCUTECH INSULATION 8 CONTRACTING
0,000
a.Square Feet
C.g, What
01220
d Zil Code
b,Address
413-743-3065
hone Number
e.Tele
wC5312904
Po�
area and e
Disposal
and
R Ex .Date mmldd
b.Number of floors
Fl
a Name of Trans,orter
LUDLOW
C.City!TW
01056 Telephone Number
0.Zip Code e.Telep
100 STATE STREET
b.Adores
Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
RED TECHNOLOGIES
a.Name of Tr
PORTLAND ___----
06480
O d z. Code
e Glyn-own _
3.
L.--
4
a Refuse Transfer Station and Owner
C.CI flown
MINERVA ENTERPRISES INC
a.Final Dis•osal Sile Location Name
9000 MINERVA ROAD
c.Final Dls•bsal Site Address
ddd Code
b Atldres
(860)342-1022
e. bone Number
b Adores
ee Telephone Number
d Final®
d.Cil [Town
e.State
f.Zip Code
0
p D. Certification
The undersigned hereby states,under the
10 penalties of perjury,that helshe has read the
Commonwealth of Massachusetts regulations
eo Containment or
= Encapsulation n the Removal, 453 CMR 6 00 and
CMR 7.15,, and the 310 CMR 7.1h antl ifcatin information
° to the best of h notification is beef.
0
U-
Z
6
U anf001ap doc•10102
9
Telephone Number
HEATHER CREPEAU
Name
OFFICE MANAGER 1
c.Po 11;1 Ritle
(413)563-5500
.Tell hone Number
100 STATE STREET
ton Owners Name
1
1210112008
O.Date mmlddl
ACCUTECH
-- f.Re resentin
Asbestos Notification Form•Page 3 of 3 III
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079172
Decal Number
G. 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.
HEATHER R. CREPEAU
I. Name
OFFICE MANAGER i
2 Position/Title
ACCUTECH INSULATION &CONTRACTING I
4. Representing
Authorized Signet e
12/03/2008
3 Date(mm/dd/vrry)
(413) 583-5500
5. Telephone
1100 STATE STREET
6 Address
LUDLOW J [01056
T City/Town 6. Zip Code
anf06pdrn doe•rev.2/5/04
)
Cl
)
mportant:
When filling out
forms on the
computer.use
ony the tab key
o move your
cursor-do not
use the return
key.
EX
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
2 isions.
Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079165
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
1811 NORTH KING STREET
2.Street Address
NORTHAMPTON
3.City
4135820523
6.Telephone Number
MA
4.State
5.Zip Code
B. Project Cancelled
Check here if this project is/was cancelled.
C. Project Dates
11/19/2008
1.Original Start Date(mMdd/yyyv)
3.Latest Revised Start Date(mm/dd/yyyy)
11/26/2008
2.Original End Date(mMdd/vvvv)
4.Latest Revised End Date(mMdd/yyyy)
D. Revised Project Dates
12/01/2008
1
Revised Start Date(mMdd/yyyy)
112/12/2008
2 Revised End Date Date(mm/ddlyyyy)
E. Other Project Revisions
F. Revision History
anfO6pdm.doc•rev.215/04
ECETIVE
NOV 1 9 2008
NORTHAMPTON BOARD OF HEALTH
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079165
ecal Number
G. 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.
(HEATHER R. CREPEAU
I. Name
OFFICE MANAGER
2. Position/Title
ACCUTECH INSULATION&CONTRACTING
4. Representin0
1100 STATE STREET
6. Address
duth6raed S
11/17/2008
3 Date(mm/dd/vvw)
(413)583-5500
5. Telephone
LUDLOW
7. City/Town
anf06pdrn.doc•rev.2/5/04
01056
8. Zip Code
j
)
LI
mportan0
When filling out
orms on the
computer.use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
t. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079164
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
811 NORTH KING STREET
2.Street Address
NORTHAMPTON
3.City
4135820523
6.Telephone Number
MA
4.State
5.Zip Code
B. Project Cancelled
n Check here if this project is/was cancelled.
C. Project Dates
11/06/2008
1.Original Start Date(mm/dd/yyyy)
3.Latest Revised Start Date(mnVdd/yyyy)
11/14/2008
2.Original End Date ImmrddNWV)
4.Latest Revised End Date(mm/dd/yyyy)
D. Revised Project Dates
11/12/2008
1.Revised Start Date(mm/dd/yyyy)
1
11/21/2008
2.Revised End Date Date(mrTdd/yyyy)
E. Other Project Revisions
F. Revision History
anf06pdrndoc-rev.2/5/04
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079164
Decal Number
G. 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.
HEATHER R. CREPEAU
1. Name
OFFICE MANAGER
2, Position/Title
ACCUTECH INSULATION &CONTRACTING
4, Representing
Authorized Sion ure
11/06/2008
3. Date(mm/dd/vvvv)
413)583-5500
5 Telephone
100 STATE STREET
6. Addre
LUDLOW
7. Crty/Town
anro6pdm.doc•rev.215/04
01056
8 Zip Code
1 -
m porta n
Nhen filling out
erns on the
:ampule'',use
ynly the tab key
a move your
,ursor-do not
fse the return
v
INSTRUCTIONS
1_ This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100080428
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
811 NORTH KING STREET
2-Sheet Addre
NORTHAMPTON
3.City
4135820523
6.Telephone Number
MA
4.State
5.Zip Code
B. Project Cancelled
Check here if this project is/was cancelled.
C. Project Dates
11/06/2008
1.Original Start Date(mm/ddlvryv)
3.Latest Revised Start Date(mm/dd/yyyy)
11107/2008
2.Oriainat End Date(mm/ddlvvvv)
4.Latest Revised End Date(mm/dd/yyyy)
D. Revised Project Dates
111/07/2008
1.Revised Start Date(mmfdd/yyyy)
11/0712008
2.Revised End Date Date(mm/dd/yyyv)
1
E. Other Project Revisions
F. Revision History
anfo6pdrn.doc•rev.2/5/04
n
a,
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100080428
Decal Number
G. 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.
HEATHER R. CREPEAU
I. Name
OFFICE MANAGER
2 Position/Title
ACCUTECH INSULATION &CONTRACTING
4. Representing
Au rized S tune f C'l
11/0612008
3 Date(mm/dd/ww)
(413) 583-5500
5 Telephone
100 STATE STREET
6. Address
LUDLOW
]. City/Town
anf06pdm.doc rev.2/5/04
01056
8. Zip Code
3
ant:
filling out
rn the
ter,use
tab key
e your
-do not
a return
3
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 0 6
A. Facility Location
RUCTIONS
is form is
available for
e filing of
,ct date
ions.
tiler project
number.
'alidate that
project
tion Its correct
he entered
al.
Enter your new
Oct dales.
Certify your
ification.
bmil date
angel.
MASSACHUSETTS HIGHWAY DEPARTMENT
Name of Name of Facilii
11 NORTH KING STREET
2.Street Address
NORTHAMPTON
3 Cy
4135820523
6 Telephone Number
B. Project Cancelled
Li Check here if this project is/was cancelled.
C. Project Dates
10/23/2008
1.Ori•inal Start Date mmldd
kb
3.Latest Revise dlam)
D. Revised Project Dates
1012712008
t.R evised Start Date ddlyyyy)
E. Other Project Revisions
II
MA
4State
10/3112008
Decal Number
2_Ori•inal End Date mMdd
5.Zip Cade
AS
4.Latest Revised mlddlyyyy)
Z.Revised En tl Dale Date(mnalddlyyyy)
F. Revision History —
ED
E :09/3012008 0 SHOULD BE 300 SQUARE FEET.V: CORRECT ANSWER FOR SECTION A,
anfo6pdrn doe-rev.2)5/04
D) C f d
OCT 2 4 2008
NORTHAMPTON BOARD OF HEALTH
e
Ira a
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079158
Decal Number
G. 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.
HEATHER R. CREPEAU
1. Name
ADMINISTRATIVE ASSISTANT
2. Position/Title
ACCUTECH INSULATION &CONTRACTING
4. Representing
100 STATE STREET
6. Address
LUDLOW 101056 __
8 Zip Code
i
Authorized Sin ure
[10/22/2008
3_ Date(mm/dd/WW)
(413( 583-5500
5. Telephone
7. City/Town
anfo6pdrn.dos-rev.2/5/04
Ur'E.
` 't
Ja. ..
0 Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
1100080428
Decal Number
A.
1.
Asbestos Abatement Description
a. Is this facility fee exempt-city,town, district, municipal housing authority, owner-occupied
residence of four units or less?❑✓ Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
MASSACHUSETTS HIGHWAY DEPARTMENT
a.Name of Facility
NORTHAMPTON 1MA
c.City/Town d State
3. Worksite Location:
I All sections of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310 5.
CMR 7.15
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 612
6.
7.
0.
BASEMENT
a.Building Name/Building Location
Is the facility occupied? Iii Yes
b.Building#
No
1
Asbestos Contractor:
ACCUTECH INSULATION 8 CONTRACTING Iry
a Name
LUDLOW 01056
d.Zip Code
C.City/Town
AC000005
f DOS License Number
PERRY KNICKERBOCKER
h.Facility Contact Person
BRANDON E BESAW
a.Name of On-Site Supervisor/Foreman
N/A
a.Name of Project Monitor
N/A
a Name of Asbestos Analytical Lab _
111/06/2008
a.Project Start Date(mndddlyyyy)
7:00-5:00
Blanket Decal Number
1811 NORTH KING STREET
b.Street Address
01060 J
e Zip Code
C.Wing
(413)582-0523
f Telephone Number
L
d.Floor
e.Room
1100 STATE STREET
b.Address
14135835500
e.Telephone Number
g. Contract Type'. ❑Written ❑Verbal
-.Contact Person's Title
AS070407
b.Supervisor/Foreman DOS Certification Number
I_
b. Project Monitor DOS Certification Number
■
Date(mm/dd/yyyy)
b.Asbestos Analytical Lab_DOS Certification Number
11/07/2008 I
b. En
__._._. iN/A
C.Work hours Mon-Fri.
10 a What type of project is this?
❑Demolition
❑ Repair
Z. Renovation
❑ Other, please specify:
11. a. Check abatement procedures:
(71 Glove bag
❑ Enclosure
❑Cleanup
❑ Full containment
❑ Encapsulation
❑ Disposal only
❑Other, specify:
d.Work hours Sat-Sun.
12. Is the job being conducted: 7; Indoors? I`.l Outdoors?
anf001 ap dog•10/02
Asbestos Notification Form•Page I of 3 U
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100080428
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
30
a.Total pipes or ducts(linear g)
c.Boiler,breaching,duct,tank
surface coatings Lin.ft.
ogler surfaces(square
Sq.fl. a.Insulating cement
e.Corrugated or layered paper ! f.Trowel/Sprayer coatings
pipe insulation Lin.ft. Sq.ft.
g.Spray-on fireproofing
I.Cloths,woven fabrics
K.Thermal,solid core pipe
insulation
Lin.ft.
Sq ft ( h.Transite board,wall board
Lin.ft
30
Lin.fl. Sq.ft I.Speci fy
1
Other,please specify:
Lin.ft.
Lin.ft.
Lin.ft.
Lin.ft.
Sq.ft.
Sq.fl.
14. Describe the decontamination system(s)to be used:
SEAL CRITICALS W/6MIL POLY, PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NEG
15. 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
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
N/A
a.Name of DEP Official
1
J
1
c.Date(mmlddryyyy)of Authorization _ Ld.DEP Waiver
e.Name of DOS Official rf.DOS Official Title
g.Date(mm/ddlyyyy)of Authorization h DOS Waiver
b.Title
N/A
° 17. Do prevailing wage rates as per M.G.L. c. 149. §26. 27 or 27A—F apply to this project? RA Yes❑No
° B. Facility Description
0
1 Current or prior use of facility
OFFICE SPACE
2. Is the facility owner-occupied residential with 4 units or less? L 1 Yes iJ No
3.
MASSACHUSETTS HIGHWAY DEPARTMEN 1 1811 NORTH KING STREET
a.Facility Owner Name b.Address
NORTHAMPTON 1 10, 1060 1413-582-0523
c.City/Town d.Zip Code e.Telephone Number area code and extension)
PERRY KNICKERBOCKER I 1
4' a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address
1 ! _ 413-582-0523
Q C.City/Town d Zip Code e Telephone Number(area code and extension)
anf001ap.doc•10102
Asbestos Notification Form•Pa ea a 2
DCommonwealth of Massachusetts
Asbestos Notification Form ANF-001
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19 000
100080428
Decal Number
B. Facility Description (cont.)
5' a.Name of General Contractor
c.City/Town
COMMERCE& INDUSTRY
I.Contractor's Worker's Comp.Insurer
What is the size of this facility?
d.Zip Code
J L
b.Address
I I
e.Telephone Number(area code and extension)
WC5312904
rg.Policy Number
130,000
a.Square Feet
11/04/2008
h.Exp.Date(mm/dd/yyyy)
12
O.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
ACCUTECH INSULATION &CONTRACTING
a.Name of Transporter
LUDLOW
01056
c.City/Town d.Zip Code
100 STATE STREET
b.Address
(413)583-5500
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
RED TECHNOLOGIES
a.Name of Transporter
PORTLAND J 06480 J
City/Town d Zio_Code
a [ _
11
a.Refuse Transfer Station and Owner
l
c.City/Town J cl Zip Code_
4. MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
OH 44688
e.State f.Zip Code
173 PICKERING STREET
b.Address
(860)342-1022
e.Telephone Number
b.Address
e.Telephone Number
O.Final Disposal Site Location Owner's Name
[WAYNESBURG
d.CS/Town
g.Telephone Number
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
° t th b t f h's/h k leedg d b F f
z
anf001ap.doc•10/02
[HEATHER R.CREPEAU
a. Name
(ADMIN.ASSISTANT 10/24/2008
c.Position/Title d.Date fmm/dd/yyyy)
1(413) 583-5500 J ACCUTECH
e.Telephone Number _ f Representing -
100 STATE STREET
9 Address
'LUDLOW 1
01056
n.City/Town i.Zip Code
.y2
b.Authorized Stlnature
Go To Top
Asbestos Notification Form•Page 3 of 3 1.
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention—Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079158
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4 Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
Name of Facility
811 NORTH KING STREET
2.Street Address
NORTHAMPTON
3.City
4135820523
6.Telephone Number
MA
4.State
5 Zip Code
B. Project Cancelled
Check here if this project is/was cancelled.
C. Project Dates
110/23/2008
1.Original Start Date(mm/dd/yvyy)
3 Latest Revised Start Date(mm/dd/yyyy)
110/31/2008
2 Original End Date(mm/dd/vwv)
4 Latest Revised End Date lmm/dd/yyyy)
D. Revised Project Dates
1.Revised Start Date(mm/dd/yyyy)
2.Revised End Date Date(mm/dd/yyyy)
E. Other Project Revisions
CORRECT ANSWER FOR SECTION A, QUESTION 13F SHOULD BE 300 SQUARE FEET.
F. Revision History
anfO6pdmdoc•rev.2/5/04
OCT - 1 2008
J
NORTHAMPTON BOARD OF HEALTH
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100079158
Decal Number
G. 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.
HEATHER R.CREPEAU
1 Name
ADMINISTRATIVE ASSISTANT
2 Position/Title
ACCUTECH INSULATION 8 CONTRACTING
4. Representing
Authorized Signal re
09/30/2008
3 Date(mm/dd/WV4)
0413) 583-5500
5 Telephone
100 STATE STREET
6. Address
LUDLOW
7 City/Town
anf06pdm doc•rev.215104
01056
8 Zip Code
Important:
Wnen filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
1 All sections of this
form must be
completed in order
to comply with 4. Is the facility occupied?
DEP notification
requirements of 310
CMR 7.15 5. Asbestos Contractor:
and the Division
of Occupational LACCUTECH INSULATION &CONTRACTING It
uDOiS)
Safety( a.Name
notification LUDLOW
requirements of 453
CMR 6.12 c,CI /Town
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100079158
Decal Number
A. Asbestos Abatement Description
1. a. Is this facility fee exempt-city,town, district, municipal housing authority, owner-occupied
residence of four units or less?❑Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
[MASSACHUSETTS HIGHWAY DEPARTMENT
a.Name of racAli
NORTHAMPTON
c.City/Town
3. Worksite Location:
PHASE 4 ROOMS 216-219
a.Building Name/Building Location
MA
d.State
b.Building#
Yes ❑No
ry
o 10 a What type of project is this?
6.
7.
8
9.
J
01056
d.Zip Code
AC000005
t DOS License Number
KRISTEN WELLS
Faullty Contac
BRANDON E BESAW
a Name of On-Site Supervisor/Foreman
URS
a Name of Project Monitor
URS
a Name of Asbestos Malytical Lab
10/23/2008
a.Project Start Date(mndd/yyyy)
7:00-5:00
Blanket Decal Number
811 NORTH KING STREET
b.Street Address
01060
e.Zip Code
C.Wing
(413) 582-0523
f.Telephone Number
d Floor
1100 STATE STREET
e Room
b.Address
4135835500
e.Telephone Number
g. Contract Type:
Written ❑Verbal
I.Contact Person's Title
AS070407
b.Supervisor/Foreman DOS Certification Number
AM061710
b.Project Monitor DOS Certification Number
IAA000175
b.Asbestos Analytical Lab DOS Certification Number
110/31/2008
b End Date tmm/ddf
N/A
c.Work hours Mon-En.
o ❑ Demolition • Renovation
❑Repair ❑Other, please specify:
11. a.Check abatement procedures.
0
U-
z
C
❑Glove bag
❑ Enclosure
❑ Cleanup
Full containment
12. Is the job being conducted:
• anf001ap.doc•10/02
❑ Encapsulation
❑ Disposal only
Other, specify:
0
d.Work hours Sat-Sun.
b.Describe
CAULKING REMOVAL
b.Describe
❑ Indoors? • Outdoors?
Go To Top
Asbestos Notification Form•Page 1 of 3•
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100079158
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
300
a.Total pipes or ducts(linear ft)
c.Boiler,breaching,dud,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
1800
b.Total other surfaces(square fl)
Lin.fl. Sq.if
Lin.ft. Sq.ft.
Lin ft.
Lin ft
Lia ft.
Sq
5 . .
Sq.fl. I.Specify
d. Insulating cement
f.Trowel/Sprayer coatings
h Transite board,wall board
j.Other,please specify
Lin.ft. Sq.ft.
300
Lin.ft. S .ft.
Lin-ft.
1800
Lin.if Sq.fl
TILE& MASTIC
14. Describe the decontamination system(s)to be used:
SEAL CRITICALS W/6MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNIT &INSTALL AIR
15. 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
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
N/A
a.Name of DEP Official
c Date(mmlddlyyyy)of Authorization
IN/A
e Name of DOS Official
g Date(mn ddlyyyv)of Authorization
b.Title
d DEP Waiver#
f.DOS Oaual Title
[
h.DOS Waiver#
° 17. Do prevailing wage rates as per M.G.L. c. 149, §26,27 or 27A—F apply to this project? 51 Yes ❑ No
° B. Facility Description
O 1
0
Current or prior use of facility
OFFICE SPACE
2 Is the facility owner-occupied residential with 4 units or less? ❑Yes Ri No
[MASSACHUSETTS HIGHWAY DEPARTMEN
3 a.Facility Owner Name
o [NORTHAMPTON
o c.City/Town d.Zip Code
KRISTEN WELLS
a.Name of Facility Owner's On-Site Manager
811 NORTH KING STREET
01060
z
cc
4
b Address
413-582-0523
e.Telephone Number(area code and extension)
• anfool ap.doc•10/02
c.City/Town
d Zip Code
b.On-Site Manager Address
413-743-3065
e.Telephone Number(area code and extension)
Asbestos Notification Form Pa ea a 2
Note'.Transfer
Stations must
comply v•N the
Solid Waste
Division
Regulations 310
CMR 19.000
ca
0
0
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100079158
i
Decal Number
B. Facility Description (cont.)
5' a.Name of General Contractor
BURKE CONSTRUCTION
ADAMS
c.City/Town
COMMERCE 8,INDUSTRY
f.Contractor's Workers Comp.Insurer
6. What is the size of this facility?
01220
d.Zip Code
6 RENFREW STREET
b.Address
413-743-3065
e.Telephone Number(area code and extension)
WC5312904
q.Policy Number
130,000
a.Square Feet
11/04/2008
h.Exp.Date(mMdd/yyyy)
2
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
ACCUTECH INSULATION &CONTRACTING
a Name of Transporter
LUDLOW
C.City/Town
01056
d Zip Code
1100 STATE STREET
b.Address
x(413) 583-5500
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site'.
3
4
!RED TECHNOLOGIES
a.Name of Transporter
PORTLAND
C.City/rown
06480
d.Zip Code
173 PICKERING STREET
b.Addre
(860) 342-1022
e.Telephone Number
a Refuse Transfer Station and Owner
C.Cay/Town
d.Zip Code
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
OH
e.State
44688
b.Address
f.Zip Code
e.Telephone Number
b.Final Disposal Site Location Owners Name
IWAYNESBURG
d.City/Town
q.Telephone Number
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.
2
C
anf001apdoc•10/D2
HEATHER R.CREPEAU
a.Name
ADMIN.ASSISTANT
c.Position/Title
(413) 583-5500
e.Telephone Number
100 STATE STREET
q.Address
LUDLOW
n.City/Town
b.Authorize a �-
09/30/2008
d.Date(mm/ddM/vv)
ACCUTECH
I.Representing
I 101056
i.Zip Code
Go To Top
Asbestos Notification Form•Page 3 of 3 U
�3
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
a
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention— Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100077065
Decal Number
A. Facility Location
LASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
1861 NORTH KING STREET
2 Street Address
NORTHAMPTON
3 City
4135620523
6.Telephone Number
(MA
4 State
5 Zip Code
INSTRUCTIONS B. Project Cancelled
1. This form is
only available for
online tiling of
project date
revisions.
2 Enter project
decal number.
3. validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certify your
noblication.
Submit date
changes
f j Check here if this project is/was cancelled.
C. Project Dates
(09/02/2008
1-Original Start Date(mmlddlyyyy)
109/08/2008
1 Latest Revised Start Date(mmlddlyyyy)
12/31/2008
2.Original End Date(mm/dd/ )
4 Latest Revised End Date(mmlddfyyyy)
D. Revised Project Dates
09/15/2008 7 j
Revised Start Date(mm/dd/yyyy) 2. Revised End Date Date(mm/ddlyyyy)
J
E. Other Project Revisions
F. Revision History
EDEP: 08/26/2008 02:18:48 PM OTHERPROREV:CORRECT ADDRESS FOR PROJECT
LOCATION IS 811 NORTH KING STREET, NORTHAMPTON, MA.
EDEP: 06/29/2008 02:29:06 PM
antobpdrn doc•rev.2)5/04
rek
Massachusetts Department of Environmental Protection [100077065
Bureau of Waste Prevention —Air Quality Decal Number
Project Revision Notification
For Asbestos Notification ANF-001 and AC 06
G. 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.
HEATHER R.CREPEAU
1. Name
ADMINISTRATIVE ASSISTANT
2. Position/Title
ACCUTECH INSULATION &CONTRACTING
4. Representing
100 STATE STREET
6. Address
LUDLOW
7 City/Town
anf06pdrn.doc•rev.2/5/04
uthorized Signatur
09/05/2008
3 Date lmmlddlwvvl
(413) 583-5500
5. Telephone
01056
8. Zip Code
LI.11
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100075707
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
L Name of Facility
881 NORTH KING STREET
2.Street Address
NORTHAMPTON
3.City
14135820523
6.Telephone Number
MA
4 State
5.Zip Code
INSTRUCTIONS B. Project Cancelled
I This form is
only available for
online filing of
project date
revisions.
2 Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal,
4. Enter your new
project dates.
5. Certify your
notification_
Submit date
changes.
Li Check here if this project is/was cancelled.
C. Project Dates
08/18/2008
1.Original Start Date(mmlddlyyvy)
09/05/2008
12/31/2008
2 Original End Date Immlddlvvvvl
3.Latest Revised Start Date(mm/ddlyyyy) 4_Latest Revised End Date(mmlddlyyyy)
D. Revised Project Dates
I. Revised Start Date(mmrddryyyy)
2.Revised End Date Date(mmldd/yyyy)
E. Other Project Revisions
PROJECT IS ON SEVEN (7) DAY HOLD.
F. Revision History
EDEP: 08/15/2008 08:09:54 AM
EDEP: 08/21/2008 08:15:42 AM OTHERPROREV: OFFICE ERROR IN NOTIFICATION OF PHASE
ACM TO BE REMOVED: 300 SQFT TROWEL/SPRAYER COATINGS SHOULD BE 300 LF OF
WINDOW CAULKING.
anto6pdrn doc-rev. 2)5/04
ak
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100075707
Decal Number
G. 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.
HEATHER R. CREPEAU
1. Name
ADMINSTRATIVE ASSISTANT
2. Position/Title
ACCUTECH INSULATION 8 CONTRACTING
4 Representing
100 STATE STREET
6. Address
LUDLOW
Authorized Signa' re
09/0512008
3 Date(mm/dd/yyyyl
(413) 583-5500
5 Telephone
7 City/Town
anfo6pdrndoc•rev.215/04
[01056
6 Zip Code
LI
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
Aare
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
500075707
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
881 NORTH KING STREET
Street Address
ORTHAMPTON
ity
4135820523
6.Telephone Number
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
IMA
4.State
5 Zip Code
B. Project Cancelled
ri Check here if this project is/was cancelled.
2. Enter project
d ewlnumber. C. Project Dates
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Cedify your
notification.
Submit date
changes.
08/18/2008
L Onginal Start Date(mm/dd/ywy)
08/20/2008
3.Latest Revised Start Date(mm/dd/ywy)
D. Revised Project Dates
109/o5/2008
1.Revised Start Date(mm/ddlwyy)
12/31/2008
2.Original End Date(mmldC/vwv)
4 Latest Revised End Date(mm/ddlyyw)
2 Revised End Date Date(mm/ddlyyyy)
E. Other Project Revisions
F. Revision History
EDEP: 08/15/2008 08:09:54 AM
1
EDEP: 08/21/2008 08:15:42 AM OTHERPROREV: OFFICE ERROR IN NOTIFICATION OF PHASE I
ACM TO BE REMOVED: 300 SOFT TROWEL/SPRAYER COATINGS SHOULD BE 300 LF OF
WINDOW CAULKING.
anfo6pdrn.doc•rev.2/5/04
ro
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
(100075707
Decal Number
G. 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 715, and that the information contained in this notification is true and correct to the best of his/her knowledge
and belief.
!HEATHER R. CREPEAU
I. Name
[ADMINISTRATIVE ASSISTANT
2. Position/Title I [
ACCUTECH INSULATION &CONTRACTING
4. Representing
100 STATE STREET
6. Address
!LUDLOW
'7 City/Town
anfo6pdm doc•rev. 2/5/04
Authorized Sip
09/04/2008
3 Date Immfdd/ _
(413) 583-5500
5. Telephone
Ii
01056
6. Zip Code
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
Sob armrs,
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100075707
Decal Number
A. Facility Location
I MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
881 NORTH KING STREET
Street Addres
NORTHAMPTON
City
4135820523
6.Telephone Number
INSTRUCTIONS
L This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal
4 Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
H MA
4.State
1
B. Project Cancelled
n Check here if this project is/was cancelled.
5.Zip Code
C. Project Dates
10811812008
t.0 a Start Date mm/ddl
08/20/2008
3.Latest Revised Start Date(mmlddlyyyy)
j 12/31/2008
2.Original End Date(mmldd/WW) 1
4 Latest Revised End Date(mm/dd/yyyy)
D. Revised Project Dates
1.Revised Start Date(mmldd/yyyy) (2.Revised End Date Date(mm/d /yyyy)
E. Other Project Revisions
PROJECT IS ON SEVEN (7) DAY HOLD.
F. Revision Histo
EDEP: 0811512008 08:09:54 AM
AUG 2 9 2008 n I
I
NORTHAMPTON BOARD OF HEALTH
EDEP: 06(21/2008 08:15:42 AM OTHERPROREV:OFFICE ERROR IN NOTIFICATION OF PHASE I
ACM TO BE REMOVED: 300 SOFT TROWEL/SPRAYER COATINGS SHOULD BE 300 LF OF
WINDOW CAULKING.
anf06pdrn doc•rev_95/04
•
e
..
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
'100075707
Decal Number
G. 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.
'HEATHER R.CREPEAU
1. Name
!ADMINISTRATIVE ASSISTANT
2. Position/Title
IACCUTECH INSULATION 8 CONTRACTING
4. Representing
1100 STATE STREET
6. Address
Authorized Signature
108/27/2008
3 Date lmm/dd/vvWl
L413)583-5500
5 Telephone
1LUDLOW
7. City/Town
anfO6pdmdoc•rev.2/5/04
1 101056
8 Zip Code
f Z
v �
Important
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do no
use the retu
key
a,
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention - Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
1100077065
Decal Number
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
1 NORTH KING STREET
et-
2Street Address ----.-
1NORTHAMPTON
3 City
14135820523_
6 Telephone Number
EX
INSTRUCTIONS
1 This form is
only available for
online filing of
project date
revisions.
2 Enter project
decal number.
3 Validate that
the project
location is correct
for the entered
decal.
4 Enter your new
project dates.
5 Certify your
notification.
Submit date
changes
4 Stale 5 Zip Code
B. Project Cancelled
Li Check here if this project is/was cancelled.
C. Project Dates
109,02/2008
1.Original Start Date fmmldd/yyyy)
3 Latest Revised Start Date(mm/dd/yyyy)
D. Revised Project Dates
109/08/2008
1.Revised Start Date(mm/dd/yyyy)
E. Other Project Revisions
'12/31/2008 _
2.Original End Date Imm/tld/yWYi_
4.Latest Revised End Date(mm/dd/yyyy)
J
2 Revised End Date Date(mm/dd/yyyy)
{I_E-cn n
J 4I SEP - 2 2008
NORTHAMPTON BOARD OF HEALTH
F. Revision History
EDEP: 08/26/2008 02:18:48 PM OTHERPROREV: CORRECT ADDRESS FOR PROJECT
LOCATION IS 811 NORTH KING STREET, NORTHAMPTON, MA.
anfc6pdm.doc•rev.2/5/04
ANS
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention — Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
00077065
Decal Number
G. Certification
The undersigned hereby states,under the penalties of perjury,that he/she has read the Commonwealth CMR 6.00 and 310
Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,
CMR 7.15,and that the information contained in this notification is true and correct to the best of his/her knowledge
and belief.
7 j
HEATHER R CREPEAU �
--- —— -__-_ AOIM1Orizetl Sipnatu a __
I. Name -- _ _ -- _.___ -
(ADMINISTRATIVE ASSISTANT X108/2912008
3. Date(mm/ad/vwyl
2. Position/Tllle
■ACCUTECH INSULATION &CONTRACTING 1(413) 583-5500
�---- - --' "—— 5 Telephone..
4. RePraS �.., __ --
100 STATE STREET __..—__ -- - ---------'
6. Address
.LUDLOW 11056
7
� ___. .
7. c•rylrown 8 Zip Code
anfo6pdrn doc•rev.2/5/04
I:-
Tii: J
\/
7 v.
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-de not
use the return
key.
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Cedi(y your
notification.
Submit date
changes.
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention –Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
1100077065
Decal Number
A. Facility Location
(MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
1881 NORTH KING STREET
2.Street Address
(NORTHAMPTON
3.City
14135820523
6.Telephone Number
1
(
IMA
`a.State._—
5.Zip Code
B. Project Cancelled
Check here if this project is/was cancelled.
C. Project Dates
109/02/2008
1.Ori,inal Start Date mm/d
1A
3.Latest Revised Start Date(mm/dd/nyy)
[12/31/2008
2.Original End Date(mmlddlvyyv)
J 4 Latest Revised End Date(mn/ddlyyyy)
D. Revised Project Dates
—1 I
1.Revised Start Date(mmlddlyyyy) 2 Revised End Date Date(mmlddlyyyy)
E. Other Project Revisions
CORRECT ADDRESS FOR PROJECT LOCATION IS 811 NORTH KING STREET,
NORTHAMPTON, MA.
F. Revision Histo
NORTHAMPTON BOARD OF HEALTH
anfo6pdm doc•rev.2/5/04
e
Ask
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100077065
Decal Number
G. 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.
!HEATHER R.CREPEAU j
1. Name ,A Mound Signature
'ADMINISTRATIVE ASSISTANT j 108/26/2008
2. Position/Title 1 Date Immlddamty)
1ACCUTECH INSULATION &CONTRACTING 1(413) 583-5500
4. Representing 5 Telephone
1100 STATE STREET
6. Address
!LUDLOW
7. City/Town
anto6pdmdot•rev.2/5/04
[01056
8 Zip Code
1
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
a AI
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
1100075707
Decal Number
A. Facility Location
(MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
881 NORTH KING STREET
2 Street Address
(NORTHAMPTON I MA
3.City ___ 4.State
14135820523
6.Telephone Number
5.Zip Code
B. Project Cancelled
Check here if this project is/was cancelled.
C. Project Dates
'08/18/2008
1 Original Stan Date(mm/ddfWyv)
(08/20/2008
3.Latest Revised Stan Date(mmlddlyyryq
j 112/31/2008
2 Original End Date(mmldd/vvWl
4 Latest Revised End Date(mm/ddlyyyy)
D. Revised Project Dates
1.Revised Start Date(mmlddlyyyy)
I I
2 Revised End Date Date(mmltldlyyyy)
E. Other Project Revisions
CORRECT ADDRESS FOR PROJECT LOCATION IS 811 NORTH KING STREET,
NORTHAMPTON,MA.
F. Revision History
EDEP: 08/15/2008 08:09:54 AM
EDEP: 08/21/2008 08:15:42 AM OTHERPROREV: OFFICE ERROR IN
ACM TO BE REMOVED: 300 SOFT TROWEL SPRAYER COATINGS SHOULD NOTIFICATION 3 PHASE
300 F OF
WINDOW CAULKING.
anfo6pdm.disc•rev.215104
(100075707
Pak
p
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
Decal Nu
G. Certification
The undersigned hereby states, under the penalties of perjury,that he/she has read the
C m 6 n0 and 310 th
1f0
Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,
CMR 7.15,and that the information contained in this notification is true and correct to the best of his/her knowledge
and belief.
[HEATHER R.CREPEAU
1. Name Apt prized Sig .lure [
[ADMINISTRATIVE ASSISTANT 108/2612008
2. Position/Title 3. Date(mm/cid/ M)
IACCUTECH INSULATION S CONTRACTING 1(413) 583-550.0 _ 1
4. Representing 5. Telephone
1100 STATE STREET
6. Address
'LUDLOW
7. City/Town
a nfa6pdm doe•rev.2/5/04
1 [01056
8 Zip Code
1
1
�3
mportant:
Nhen tilling out
orms on the
omputer.use
knly the tab key
o move your
:ursor-do not
use the retu
key.
tisk
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
[100075707
Decal Number
A. Facility Location
[MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
[
1881 NORTH KING STREET
2.Street Address
NORTHAMPTON - [ (MA
City ._ a.Stale
4135820523
6.Telephone Number
INSTRUCTIONS
1. This form is
o Iy available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes
B. Project Cancelled
fI
Check here if this project is/was cancelled_
C. Project Dates
5 Zip Code
L8/18/2008
1.Original Start Date(mmldd/my)
[08/20/2008
3.Latest Revised Start Date(mmlddlyyyy)
112/31/2008
2.Original End Date(mmlddtml
4.Latest Revised End Date(mm/ddlyyyy)
[
D. Revised Project Dates
[
1.Revised Start Date(mmlddlyyyy)
2.Revised End Date Date(mmldd/yyyy)
E. Other Project Revisions
OFFICE ERROR IN NOTIFICATION OF PHASE I ACM TO BE REMOVED: 300 SQFT
TROWEL/SPRAYER COATINGS SHOULD BE 300 LF OF WINDOW CAULKING.
F. Revision History
EDEP:08/15/2008 08:09:54 AM
anfO6pdrn doc•rev.215/04
ECEIVE
1 AUG 2 5 2005 114)
NORTHAMPTON BOARD OF HEALTH
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100075707
Decal Number
G. 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.
HEATHER R. CREPEAU
1. Name
ADMINISTRATIVE ASSISTANT
2. Position/Title
IACCUTECH INSULATION &CONTRACTING
4. Reece en
Authorized Sion ure
08/21/2008
3. Date(mm/dd/vvvy)
1(413)583-5500
5. Telephone
100 STATE STREET
6. Address
(LUDLOW
7. City/Town
anfo6pdrn.don•rev.2/5/04
1, 101056
8 Zip Code
When filling the
forms use
computer,te k
the t,tab key
to move move dour
cursor-do not
key e the return
key.
4
aim
Itak
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100075707
Decal Number
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5 Certify your
notification.
Submit date
changes.
A. Facility Location
[MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
881 NORTH KING STREET
2.Street Address
[NORTHAMPTON
3.City
[4135820523
6.Telephone Number
[MA
[
4.State
5.Zip Code
B. Project Cancelled
U Check here if this project is/was cancelled.
C. Project Dates
10811812008
1.Original Start Date(mmlddlyy•y)
[
3.Latest Revised Start Date(mm/dd/yyyy)
11213112008
2.Od.inal End Date mmlddl
4.Latest Revised End Date(mm/dd/yyyy)
D. Revised Project Dates
[08/2012008
[
1 Revised Start Date(mm/dd/yyyy)
2.Revised Entl Date Dale(mm/ddlyyyy)
E. Other Project Revisions
F. Revision History
lECEHE AUG 1 8 2009
NORTHAMPTON BOARD Of HEALTH
anfo6pdrn.doc•rev.215104
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100075707
Decal Number
G. 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.
HEATHER R. CREPEAU
1. Name
ADMINISTRATIVE ASSISTANT
2. Position/Title
ACCUTECH INSULATION&CONTRACTING
oozed Sionatu
08115/2008
3. Date(mm/edlwvv)
(413) 583-5500
4. Re resentin 5. Tele hone
100 STATE STREET
6. Address
'LUDLOW
7. City/Town
anf06pdrn.doc•rev.215104
01056
6. Zip Code
r( 101 ,• o
• 7
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100075707
Decal Number
A. Asbestos Abatement Description
1.
a. Is this facility fee exempt-city,town, district, municipal housing authority, owner-occupied
residence of four units or less?E Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
'MASSACHUSETTS HIGHWAY DEPARTMENT
a.Name of Facility
NORTHAMPTON
c.City/Town
Blanket Decal Number
881 NORTH KING STREET
3. Worksite Location:
1.All sections of this
form must be
completed in order
to comply with 4
DEP notification
requirements of 310 5
CMR 7 15
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 612
1ST&2ND FLOORS
a.Building Name/Building Location
Is the facility occupied?
Fl
MA
d State
b.Building#
Yes ❑No
b.Street Address
101060
e.Zip Code
I 1
c.Wing
Asbestos Contractor:
ACCUTECH INSULATION &CONTRACTING P;
a.Name
LUDLOW
c.City/Town d Zip Code
01056
AC000005
DOS License Number
JOHN J. BURKE
h,Facility Contact Person
6' 'NELSON BERNARDES
a.Name of On-Site Supervisor/Foreman
7 'URS
a Name of Project Monitor
8' 'URS
a.Name of Asbestos Analytical Lab
0811812008
g
o a.Project Start Date(mmlddlyyyy)
'7:00.5:00
c.Work hours Mon-Fri.
N
o 10 a What type of project is this?
o ❑ Demolition Renovation
❑Repair ❑Other, please specify:
Fl
11. a.Check abatement p ocedures:
° ❑Glove bag
❑Enclosure
LL ❑Cleanup
Full containment
z
N
12. Is the job being conducted
anf001ap doc•10/02
❑ Encapsulation
❑Disposal only
❑Other, specify:
[4413) 582-0523
E.Telephone Number
d Floor
e.Room
1100 STATE STREET
b.Address
[4135835500
e.Telephone Number
g. Contract Type: 0 Written ❑Verbal
Contact Person's Title
(AS072621
b.Supervisor/Foreman DOS Certification Number
'AM061710
b.Project Monitor DOS Certification Number
,000175
b.Asbestos Analytical Lab DOS Certification Number
'1213112008
b.End Date Immlddl
NI
NIA
d.Work hours Sat-Sun.
Indoors? 11 Outdoors?
Asbestos Notification Form•Page 1 of 3
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100075707
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
0
a.Total pipes or ducts(linear ft)
c.Boiler,breaching,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
18500
b Total other surfaces(square I)
Lin.ft
Sq.ft
Lin.ft. Sq.ft.
d.Insulating cement
f.Trowel/Sprayer coatings
Lft. Sq.ft. h.Transite board,wall board
Lin.ft. S ft. I.Other,please specify:
Lin.ft. Sq ft. I.Specify
Lin.ft.
Lin.ft.
ft.
Sq.ft.
300
Sq.ft.
Lin.ft
18200
S9.ft.
VAT&MASTIC
14. Describe the decontamination system(s)to be used:
SEAL CRITICALS W/6MIL POLY, ATTACH 3 STAGE DECONTAMINATION UNIT & INSTALL AIRS
15. 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
16
N
17. Do prevailing wage rates as per M.G.L. c.
For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
b.Title
tl.DEP Waiver#
N/A
a.Name o
c.Date(mnVdd/yyyy)of Authorize
on
N/A
e.Name of DOS Official
g Date(mm/dd/yyyy)of Authorization
0
0
2
't.DOS Official tine
h DOS Waiver#
49, §26, 27 or 27A—F apply to this project? Fl Yes❑No
B. Facility Description
OFFICE SPACE
1 Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes Fl No
'MASSACHUSETTS HIGHWAY DEPARTMENJ
3' a.Facility Owner Name
NORTHAMPTON
c.City/Town
JOHN J. BURKE
4' a.Name of Facility Owners On-Site Manager
101060
O.Zip Code
c.City/Town d.Zip Code
anf001ap.doc•10/02
'881 NORTH KING STREET
b.Address
1413-582-0523
e.Telephone Number(area code and extension)
b.On-Site Manager Address
413-743-3065
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa ea a 2
Commonwealth of Massachusetts
LI Asbestos Notification Form ANF-001
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
0
0
0
0
LL
Z
C
100075707
Decal Number
B. Facility Description (cont.)
5.
BURKE CONSTRUCTION
a.Name of General Contractor
ADAMS
C.City/Town
01220
d Zip Code
COMMERCE& INDUSTRY
C Contractor's Worker's Comp.Insurer
6. What is the size of this facility?
6 RENFREW STREET
b.Address
1413-743-3065
e.Telephone Number(area code and extension)
1WC5312904
q.Policy Number
30,000
a.Square Feet
11/04/2008
It Exp.Date(mm/dd/yyyy)
2
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
ACCUTECH INSULATION &CONTRACTING
a.Name of Transporter
LUDLOW 1 01056
c.City/Town d.Zip Code
1100 STATE STREET
b.Address
11(413) 583-5500
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
3
4
RED TECHNOLOGIES
a.Name of Transporter
PORTLAND
c.City/Town
06480
d.Zip Code
1173 PICKERING STREET
b.Address
1(860) 342-1022
e.Telephone Number
a.Refuse Transfer Station and Owner
d.Zip Code
c.City/Town
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
OH
e.State
44688
f.Zip Code
b.Address
e.Telephone Number
b.Final Disposal Site Location Owners Name
IWAYNESBURG
d.City/Town
g.Telephone Number
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.
anf001apdoc•10102
HEATHER R. CREPEAU
a.Name
ADMIN.ASSISTANT
C.Position/Title
(413) 583-5500
e.Telephone Number
1100 STATE STREET
q.Address
'LUDLOW
h.City/Town
b.Authorized Si nature
07/25/2008
d.Date(nun/Ltd/
ACCUTECH
I.Re.resentin•
01056
i.Zip Code
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Asbestos Notification Form•Page 3 of 3