811 (1st & 2nd floor) Project Revision Notifications & Asbestos Notification Forms 2008 a,
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
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5. Asbestos Contractor:
•
100078086
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? o Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
MASSACHUSETTS HIGHWAY DEPARTMENT]
a.Name of Facility
NORTHAMPTON ▪ MA
C.City/Town d Slate
3. Worksite Location:
1ST&2ND FLOORS
a.Building Name/Building Location
4. Is the facility occupied?
.15
e Division
upational
(DOS)
ition
ments of 453
12
6.
7.
8.
• 9
0
0
Yes
J
b.Building#
No
ACCUTECH INSULATION&CONTRACTING IP
a.Name
LUDLOW
c C tyrrown
01056
d.Zip Code
AC000005
f.DOS License Number
JOHN J. BURKE
h Facility Contact Person
MICHAEL MURRAY
a.Name of On-Site Supervisor/Foreman
URS
a.Name of Project Monitor
URS
a.Name of Asbestos Analytical Lab
X09/23/2008
a.Project Start Date(mm/dd/yyyy)
7:00-5:00
Blanket Decal Number
811 NORTH KING STREET
b.Street Address
''.01060 1 1(413) 582-0523
e.Zip Code
f.Telephone Number
FT-
c.Wing
d.Floor e.Room
J
100 STATE STREET
b.Address
4135835500
e.Telephone Number
g. Contract Type: U Written ❑Verbal
c.Work hours Mon-Fri.
i.Contact Person's Title
AS073359
b.Supervisor/Foreman DOS Certification Number
AM061710
b.Protect Monitor DOS Certification Number
AA000175
b.Asbestos Analytical Lab DOS Certification Number
112/31/2008
b_Fnd Date Imm/dd/
IN/A
10 a What type of project is this?
O ❑ Demolition
• ❑Repair
11. a. Check abatement procedures:
=0
0
Renovation
❑ Other, please specify:
❑ Glove bag
o ❑ Enclosure
❑Cleanup
Full containment
z
• 12. Is the job being conducted
001ap doc•10/02
❑ Encapsulation
❑ Disposal only
[] Other, specify:
d.Work hours Sat-Sun.
r'' Indoors? Lvi Outdoors?
Go To Top
Asbestos Notification Form•Page 1 of 3
1413-582-0523
Ire.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�.
1
—N
�o
-0
ofs ANN
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100078086
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed, or
encapsulated:
[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
i.Cloths,woven fabrics
119100
b.Total other surfaces(square ft)
d Insulating cement
f.Trowel/Sprayer coatings
Lin.X.
Lin.ft.
Lin.X
Sq.ft
Sq ft
5q ft.
un n .So.n.
] i
k.Thermal,solid core pipe
insulation Lin.ft.
I h.Transits board,wall hoard
I J.Other,please specify:
VAT/ADH/WINSL
Sq.ft. I.Specify
Lin.ft.
Lin.n.
Lin ft.
Lin ft.
Sq.ft.
[300
Sq.ft.
18800
Sq.ft.
14. Describe the decontamination system(s)to be used:
1SEAL CRITICALS W/6MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNIT &INSTALL AIR 1
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 Offidal
c.Date(mMddfyyyy)of Authorization
1N/A
e.Name of DOS Official
1 lb.Title
d.DEP Waive
g.Date(mm/dd/yyyy)of Authorization
17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? ❑Yes❑No
DOS OXidal tine
h.DOS Waiver#
B. Facility Description
o 1. Current or prior use of facility:
2 Is the facility owner-occupied residential with 4 units or less? ❑Yes 0 No
all NORTH KING STREET
b.Address
OFFICE SPACE
[MASSACHUSETTS HIGHWAY DEPARTMEN
- 3' a.Fealty Owner Name
o [NORTHAMPTON 1 101060
�o c.City/Town d.Zip Code
LL
[KRISTEN WELLS 1
4' a.Name of Facility Owner's On-Site Manager
C.City/Town (d.Zip Code
I
a
ID1ap.doc•10/02
i
isfer
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to
is 310
goo LED TECHNOLOGIES
a Name of Transporter 106480
[PORTLAND J
c.CllvfTown ___ d.Zip Code
3. r
r •
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100078086
Decal Number
B. Facility Description (cont.)
1BURKE CONSTRUCTION
5 a Name of General Contractor
ADAMS
c.City/Town
`COMMERCE&INDUSTRY
L Contractors Worker's Comp.Insurer
6. What is the size of this facility?
j 101220
d Zip Code
J
16 RENFREW STREET
b.Address
X413-743.3065
e.Telephone Number(area code and extension)
1WC5312904
q.Policy Number
130,000
a Square Feet
1
111/04/2008
h.Exp.Date(mmldd/yyyy)
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
1ACCUTECH INSULATION &CONTRACTING I
a.Name of Transporter
'LUDLOW
1 101056
c.City/Town d.Zip Code
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
173 PICKERING STREET
1100 STATE STREET
b Address
1(413) 583-5500
e.Telephone Number
m
=0
-C
EMS
=o
U
a.Refuse Transfer Station and Owner
c CmRown
4. MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
19000 MINERVA ROAD
c.Final Disposal Site Address
1OH
e.State
d.Zip Code
144688
f.Zip Code
b Address
1(860)342-1022
e.Telephone Number
b Address
e Telephone Number
b.Final Disposal Site Location Owners Nam
1WAYNESBURG
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.
001apdoc•10/02
(HEATHER R.CREPEAU
a.Name
1ADMIN.ASSISTANT
c.Position/Title
'x(413) 583-5500
e.Telephone Number
1100 STATE STREET
A.Address
LUDLOW
b.City/Town
uthonzed alure
09(1012008
d Date(mm/dd/Wyy)
ACCUTECH
f.Representing
'01056
Zip Code
Go To Top
Asbestos Notification Form•Page 3 of 3 III
[4135820523
6.Telephone Number
I
ut
e
:ey
of
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
DNS
is
le for
of
!MASSACHUSETTS HIGHWAY DEPARTMENT
Name of Facility
1881 NORTH KING STREET
2_Street Address
(NORTHAMPTON
3.City
IMA
4 State
5.Zip Code
B. Project Cancelled
[—I Check here if this project is/was cancelled.
Nect
er.
C. Project Dates
that 109/02/2008
:erred 1.Original Start Date(mmldd/mY)
red 10911512008
a Latest Revised Start Date(mmldd/yyyy)
an new
as.
our D. Revised Project Dates
e
110/01/2008
1.Revised Start Date(mm/dd/YYYY)
1 [1213112008
2.Original End Date 1mm/cidh vv)
1
1
4.Latest Revised End Date(mm/ddlyyyy)
E. Other Project Revisions
F. Revision History
EDEP:0812612008 02:18:48 PM OTHERPROREV: CORRECT ADDRESS FOR PROJECT
LOCATION IS 811 NORTH KING STREET, NORTHAMPTON, MA.
2.Revised End Date Date(mmldd/yyyy)
EDEP: 08(29/2008 02:29:06 PM
dmdoc•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
1100077065
Decal Number
G. Certification
The undersigned hereby states,under the penalties of perjury,that he/she has read the CMCommonwealth 6 n0 and 3 of
Massachusetts regulations for the Removal, Containment or Encapsulation of Asbestos,453
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
(ADMINISTRATIVE ASSISTANT 1
1. Name
2.
Position/Tee
LACCUTECH INSULATION &CONTRACTING J
4, Representing
100 STATE STREET
S. Address
LUDLOW
7. City/Town
pdm doc•rev.215104
ized Siena re
0911012008
3. Date ImmmdlvyVV)
1(413) 583-5500
5. Telephone
J 101056
8. Zip Code
f
.
-atillet
L.
;I' •
Nor
vase
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
RS
for
[MASSACHUSETTS HIGHWAY DEPARTMENT
1.Name of Facility
881 NORTH KING STREET
2 Street Address
(NORTHAMPTON
3.City
14135820523
6 Telephone Number
1 [MA
a.State
5 Zip Code
B. Project Cancelled
Check here if this project is/was cancelled.
ct C. Project Dates
iat 108/18/2008
rrect 1.Original Start Date(mm/dd/yyyy)
10910512008
3.Latest Revised Start Date(mm/ddlyyyyl
r new
ur
D. Revised Project Dates
109/12/2008
1.Revised Stan Date(mm/dd/yyyy)
E. Other Project Revisions
r-
112/31/2008
2.Original End Date lmmlddlvvvy)
4.Latest Revised End Date(mmldd/yyyy)
[
12.Revised End Date Date(mmlddly
F. Revision Histo
EDEP:08/15/2008 08:09:54 AM
EDEP:08121/2008 08:15:42 AM OTHERPROREV: OFFIC - ' • : •j \� .�• • HASE I
ACM TO BE REMOVED: 300 SOFT TROWEL/SPRAY I S .' ��U t _'���i OF
WINDOW CAULKING.
m-doc•rev 2/5/04
a
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention—Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
G. Certification
The undersigned hereby states,under the penalties of perjury,that he/she has read the CMCommonwe
6 n0 and 310 of
Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,453
CMR T15,and that the information contained in this notification is true and correct to the best of his/her knowledge
and belief. _—_—1
HEATHER R. CREPEAU —__
1. Name
ADMINISTRATIVE ASSISTANT
2. Position/Title
ACCUTECH INSULATION&CONTRACTING
4. Re•resentin
100 STATE STREET
6. Address
LUDLOW
7. City/Town
n doc•rev.2/5/04
Authorized
09/11/2008
3. Date mm/dd
413) 583-5500
5. Tete•hone
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ AQ 06
A. Facility Location
i
7
v
ect
new
Facility
881881 NORTH
2.Street Address _
NORTHAMPTON
3.City
4135820523
6.Telephone Number
MA
---�' 4.Stale
B. Project Cancelled
C Check here if this project is/was cancelled.
C. Project Dates
0910212008
5 Zip Code
1.On final Start Date mm/d
10/01/2008
3 Latest Revised mmlddly
D. Revised Project Dates
1 Revised 1.Revised Stad Date(mmldtllyyyY)
E. Other Project Revisions
F. Revision Histo
DEP: 0812612008 02:18:48 PM OTHERPROREV: CORRECT ADDRESS FOR PROJECT
OCATION IS 811 NORTH KING STREET,NORTHAMPTON, MA.
12/31/2008
2 Ori.inal End Date mmldd
4.Latest Revised End Date(mm/ddlyyyy)
2.Revised End Date Date(mm/ddlyyyy)
EDEP: 0812912008 02:29:06 PM
rn Coo•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
G. Certification
p ry' the Commonwealth alt 3f
The undersigned hereby for states,Removal,Contaniment or Encapsulaton of Asbestos,the Commonwealtho
CMR 7.15,and that he inf for the Rcmoain
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 R CREPEAU A
Name 0911812008
ADMINISTRATIVE ASSISTANT
2 Roston/Title . Date
ACCUTEOH INSULATION &CONTRACTING 5I 83-550 0
c._
4. Re•resen
100 STATE STREET
66. Address
LUDLOW
7. Gityrtown
100077065
— Decal Number
im doc•rev.215/84
J
Tele•h
01056
8. Zip Code
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention—Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
A. Facility Location
MASSACHUSETTS HIGHWAY DEPARTMENT
Name of Facility
881 NORTH KING STREET
2.Street Address
NORTHAMPTON
3.City
'• 4135820523
6.Telephone Number
et
ew
B. Project Cancelled
Check here if this project is/was cancelled.
C. Project Dates
4 State
12/31/2008
1 0 ti Mal St d D ( md/\ yL_
0911212008
3.Latest Revised Start Date(mmlddlyyyy)
D. Revised Project Dates
Revised Start Date(mmlddlyyyy)
2.ori.inal End Date
E. Other Project Revisions
NEW NOTIFICATION FOR PROJECT HAS BEEN FILED WITH 9/23)08 AS THE START DATE.
5.Zip Code
4 Latest Revised End Date(mmlddlyyyy)
2 Revised End Date Date(mmIddlyyyy)
F. Revision History __
EDEP:08/1512008 08:09:54 AM
EDEP: 0812112008
BE REMOVED: 300 SQFT TROWELISPRAYER COATINGS SHOULD ABE0300 LF OF PHASE I
ACM TO
WINDOW CAULKING.
n dec•rev.215104
i
Massachusetts Department of Environmental Protection F100075707
Bureau of Waste Prevention —Air Quality Decal Number
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 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 Ciryltown
m.doc-rev.2/5/04
Authorized Signatu
09/18/2008
3. Date(mm/ddtyvvv)
11413) 583-5500
5 Telephone
j [01056
6 Zip Code