811 (room 115B) Asbestos Notification Form 2008 Important:
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forms on the
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only the tab key
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
■
100079165
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? 1H1 Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
MASSACHUSETTS HIGHWAY DEPARTMENT
a.Name of Facility
NORTHAMPTON
c.City/Town
INSTRUCTIONS 3. Worksite Location:
1.Al sections of th s
form must be
completed in order
to comply with
DEP notification
requirements of 310
CMR 7.15
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 6.12
0
PHASE 6 ROOMS 115B&
a.Building Name/Building Location
4. Is the facility occupied?
5. Asbestos Contractor:
MA
d.State
b.Building#
Yes ❑ No
ACCUTECH INSULATION &CONTRACTING n
a.Name
!LUDLOW
c.City/Town
AC000005
L DOS License Number
01056
d Zip Code
KRISTEN WELLS
h.Facility Contact Person
BRANDON E BESAW
6. a.Name of On-Site Supervisor/Foreman
T a.Name of Project Monitor
URS
8.
9
URS
a.Name of Asbestos Analytical Lab
11/19/2008
a.Project Start Date(mmiddiyyyyj
7:00-5:00
Blanket Decal Number
811 NORTH KING STREET
b.Street Address
01060
413)582-0523
e.Zip Code f.Telephone Number
C.Wing
d.Floor
116-118
e Room
100 STATE STREET
b.Address
4135835500
e.Telephone Number
g. Contract Type:
0
Written ❑Verbal
i.Contact Person's Title
AS070407
b.Supervisor/Foreman DOS Certification Number
AM061710
b.Project Monitor DOS Certification Number
AA000175
b.Asbestos Analytical Lab DOS Certification Number
11/26/2008
b.End Date mm/M1
1712 , 11111
r F I V F
c.Work hours Mon-Fri.
0 10. a. What type of project is this?
0
Z
C
12
❑Demolition Renovation
❑Repair ❑Other, please specify:
11. a. Check abatement procedures:
❑ Glove bag
❑ Enclosure
❑Cleanup
Full containment
t7
12. Is the job being conducted
anfooiap.doc•10/02
Encapsulation
❑ Disposal only
Other, specify:
O
0
b.De
vibe
NORTHAMPTON BOARD OF HEALTH
CAULKING REMOVAL
b.Describe
(✓ Indoors? U Outdoors?
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Asbestos Notification Form•Page 1 of 3
N
• 17. Do prevailing wage rates as per M.G.L. c. 149, §26,27 or 27A—F apply to this project?
a'
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100079165
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
i.Cloths.woven fabrics
k.Thermal,solid core pipe
insulation
2100
b. I otal other surfaces(square ft)
d. Insulating cement
L Trowel/Sprayer coatings
h.Transite board,wall board
j.Other,please specify.
Lin.ft.
Sq.ft.
Lin.ft. Sq.fl.
Lin.ft. Sq.ft.
J
Lin.q. Sq fi......_
Lin.ft. Sq.ft.
300
Lin.ft. Sq.ftt.
Lin.ft.
Lin.ft. a
1800
TILE&MASTIC
Lin.fl. Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used:
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.
b.Title
N/A
a.Name of DEP Official
c.Date(mmldd/yyyy)of Authorization
O.DEP Waiver#
NIA
e.Name of DOS Official
g.Date(mmldd/yyyy)of Authorization
f DOS Official Title
h.DOS Waiver#
17
Yes❑ No
° B. Facility Description
o 1 Current or prior use of facility.
0
!OFFICE SPACE
2. Is the facility owner-occupied residential with 4 units
3' a.Facility Owner Name
o !NORTHAMPTON
MASSACHUSETTS HIGHWAY DEPARTMEN
0
Z
C C.City/Town
4.
c.City/Town
01060
KRISTEN WELLS
d Zi Cop de
or less?
❑Yes
No
811 NORTH KING STREET
b.Address
413-582-0523
e.Telephone Number(area code and extension)
a.Name of Facility Owners On-Site Manager
anf001andoc•10/02
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 with the
Solid Waste
Division
Regulations 310
CMR 19.000
0
..
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100079165
Decal Number
B. Facility Description (cant.)
5' a.Name of General Contractor
IBURKE CONSTRUCTION
1
ADAMS
c.Ciry/rown
01220
d.Zip Code
COMMERCE&INDUSTRY
f Contractor's Workers Comp.Insurer
6. What is the size of this facility?
�RENFREW STREET
b.Address
413-743-3065
e.Telephone Number(area
WC5312904
q.Policy Number
30,000
a.Square Feet
code and extension)
11/04/2008
h.Exp.Date(mmlddty y)
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 j
a.Name of Transporter
LUDLOW
c.City/Town
01056
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:
3.
4
RED TECHNOLOGIES
a.Name of Transporter
PORTLAND
c.City/Town
06480
d.Zip Code
a.Refuse Transfer Station and Owner
c.City/rown
d.Zip Code
173 PICKERING STREET
b.Address
(860) 342-1022
e.Telephone Number
b.Address
MINERVA ENTERPRISES INC
a.Finat Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
OH
e.State
4688
e.Telephone Number
b.Final Disposal Site Location Owner's Name
WAYNESBURG
d.City/Tom)
f.Zip Code
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.
0
0
u-
Z
C
anf001 ap.doc•10/02
HEATHER R. CREPEAU II
a.Name
ADMIN.ASSISTANT
c.Position/Title
(413) 583-5500
e.Telephone Number
b.Au l orize• Si.nature
09/30/2006
d.Date(mmld
ACCUTECH
f Representing
100 STATE STREET
q.Address
LUDLOW
h.City/Town
01056
Zip Code
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Asbestos Notification Form•Page 3 of 3 El