811 (rooms 107,201,205) Asbestos Notification Form 2008 a
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
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?IJ Yes ❑No
b.Provide blanket decal number if applicable:
2. Facility Location:
IS
of this
Amer
MASSACHUSETTS HIGHWAY DEPARTMENT
a. cili
Name of Fa
NORTHAMPTON
c.Gitylro -_
3 Worksite Location:
PHASE 9 RMS 107,201,205
a.Building Name/Building Location
Yes 0 N
d.State
b.Building
4. Is the facility occupied?
an
of 310 5
on
rat
;of 453
Asbestos Contractor
Blanket Decal Number
b.Street Address ( ,
01060 N tuber
e Zip Code
a Wing
s
ACCUTECH INSULATION & CONTRACTING I
a.Name
01056
d.Zi•Code
413 582-0523
1.Telephone u
d Floor
100 STATE STREET
AC000005
DOS Lice
e.Room
4135835500
e.Telephone Number
0 Written ❑Verbal
g.Contract Type'.
Facilit Conlad Person
6. a.Name of
7. a Name of Pro ect Monito
8 URS I al lab
a.Name of Asbestos Anal
• 0110712009
O 9. Pro tt Staff mld a.
O 7:00-5:00
o Work hours
0 10. a.What type of project is this?
J Renovation
0 ❑Demolition 0 Other, please specify:
Repair
11. a.Check abatement procedures:
0 0Enclosure losurre ❑Disposal only
0 Cleanup es Other, specify:
0 Full containment
12. Is the job being conducted: j]Indoors?
Site S
Contact Person's Titl
AS070407
b 5u•-rvisorlForeman DOS Certification Num
NlsorfFOfeman
AM061710
b.Pro ed Monitor DOS Certification Number
LL
Iz
EQ
ini001 ap doc•10102
0112312009
• End p.Sit---1 mrddryyyY�
NIA
d Work
b
Descr
a't nC E 0 V E
NORTHAMPTON BOARD OF HEALTH
CAULKING AL
b Describe
Outdoors?
OMB
Asbestos Notification Form•Page 1 of 3 a
ek
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed enclosed, or
encapsulated'. ---
O °tat pipes ar ducts(Imear )
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
Describe the decontamination system(s)to be SEAL CRITICALS WI6MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNIT 81NSTALL AIR
7.15 and 453 CMR
Describe the containerization/disposal methods to comply with
(g):(g
ACCM M TO BE DOUBLE BAGGED O WR--RAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED
ri
2100
Lin.n.
u
Sq�J
ft Sq�i
Lin Lint Sq-ft
ft
Lint ft
Lin.ft. Sq-ft.
O.Insulating cement
f.Trowel/Sprayer coatings
P.Transite board,wall board
i Other,please specify:
Lin.ft Sa ft
Lin ft.
Lin.
ft.
Sq_fi.
b used-
14.
i th 310 CMR71
5.
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emerge
cjaale(mm)uthodzation
NIA --
e.Name Dtoe OS Official
h.DOS Waiver it
g.Date(mmladNyyy)of Authorization I to this project? �Yes❑No
26,27 or 27A—F apply 17. Do prevailing wage rates as per M G.L.c. 149, §
B. Facility Description
ial i e
1 Current or prior use of facility.
OFFICE SPACE
Yes
o
0
2. Is the facility owner-occupied residential with 4 units or less?
0
4
MASSACHUSETTS HIGHWAY DEPARTMEN
F rry Owner Name
NORTHAMPTON
ON
C.ci (Town
KRISTEN WELLS
Name of bIF a Owner
c.Cityffown
nt001apdoc• 10102
01060
d.Zi. Code
On-Site Manager er
d.rl v Code
VA
No
811
_—_ STREET
KING
b.Address
NORTH
413-582-0523
one Number a
e
Tel
rea code and extensi
b On-Site Man e Aridness
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa e a 2
i
ter
ust
h the
e
is 310
00
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
B. Facility Description (cont.)
BURKE CONSTRUCTION
a.Name of General
ADAMS
c.CI frown
OMMERCE&INDUSTRY
f.Contractor's Workers Comp.Insurer
6. What is the size of this facility?
0
N
0
100079180
Decal Number
6 RENFREW STREET
bb.Addre
413-743-3065
T I h Number(area code and extension)
WC5312904 11104/2008
q.Policy Number h.Exp.Date(mm/dd/yyyy)
30,000
a.Square Feet
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
=o
ACCUTECH INSULATION &CONTRACTING b.Address
N ri porter 01056 (413)583.5500
LUDLOW d.Zi Code e.Telephone Number
G.City/Town p
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
73 PICKERING STREET
b.Address
(860)342-1022
e.Tele•hone Number
100 STATE STREET
=o
—LL
—z
—a
3
4.
RED TECHNOLOGIES
a Name of Transoorter
PORTLAND
c.Ci /Town
a.Refuse Transfer Station and Dwner
c.CI /Town
MINERVA ENTERPRISES INC
sal Site Location Name
a.Final DIs
9000 MINERVA ROAD
F D' al Site Address _
OH
e.State
lfukt
d Zi•Code
b Addres
d.Zi•Code ee.Tele•hone Numbe
44688
C Zip Code
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.
OOtap.doc•10/02
b.Final Dis•osal Site Location Owner's Name
WAYNESBURG
d.CIry/rown
g.Telephone Number
HEATHER R.CREPEAU
a.Name
ADMIN.ASSISTANT
c.Position/Title
(413) 583-5500
Tele hone Number
e
100 STATE STREET
Addres9_s ------
LUDLOW
h.city/Town
A •
A Ih tlSg azure
09/30/2008
•
m/ t
ddM
ACCUTECH
f
e
01056
n
I.Zip Code
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Asbestos Notification Form•Page 3 of 3 1.1