811 (rooms 109-115A) Asbestos Notification Form 2008 1811 NORTH KING STREET
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RUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
1100079164
Decal Number
A. Asbestos Abatement Description
1. a. Is this facility fee exempt-cit t, town, district, municipal housing authority, owner-occupied
residence of four units or less?LI Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
(MASSACHUSETTS HIGHWAY DEPARTMENT'
a.Name of Facility
'NORTHAMPTON
c.CitylTown
3. Worksite Location:
sections of this
must be
ueted in order
mply with 4
notification
rements of 31D 5
:L15
he Division
zupationaI
ty(DOS)
cation
rements of 453
t6.12
0
0
0
1PHASE 5 ROOMS 109-115A
a.Building Name/Building Location
Is the facility occupied?
0
MA
d.State
b.Building#
Yes ❑No
Asbestos Contractor:
1ACCUTECH INSULATION &CONTRACTING 111
a Name
'LUDLOW
c.City/Town
'01056
d.Zip Code
1AC000005
f DOS License Number
'KRISTEN WELLS
h.Padlity Contact Person
6. (BRANDON E BESAW
a.Name of On-Site Supervisor/Foreman
7 1URS
a.Name of Project Monitor
Blanket Decal Number
101060
e.Zip Code
c Wing
1(413) 582-0523
f Telephone Number
P
d.Floor
1 I I
e.Room
1100 STATE STREET
b Address
14135835500
e.Telephone Number
g. Contract Type: is Written ❑Verbal
'URS
8. a.Name of Asbestos Analytical Lab
9 111/06/2008
a Project Start Date(mMdd/yyyy)
'7:00-5:00
c.Woik hours Mon-Fri.
10 a What type of project is this?
11
❑ Demolition
❑ Repair
0 Renovation
❑ Other, please specify:
a. Check abatement procedures:
o ❑ Glove bag
o ❑ Enclosure
❑ Cleanup
Full containment
z
0
❑ Encapsulation
❑ Disposal only
Other, specify:
12. Is the job being conducted: [ Indoors? (✓
I anf001 ap.doc•10/02
I.Contact Person's Title
'AS070407
b.Supervisor/Foreman DOS Cedification Number
IAM061710
b.Project Monitor DOS Certification Number
[AA000175
b.Asbestos Analytical Lab DOS Certification Number
111/14/2008
b.End Date(mmldd/yyyy)
1N/A
EudE
b
OCT - 1 2008
NORTHAMPTON BOARD OF HEALTH
1CAULKING REMOVAL
b.Describe
Outdoors?
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Asbestos Notification Form•Page 1 of 3 N
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100079164
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 fl)
c.Boiler,breaching,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
9.Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
2100
su
Lin.ft. Sq.fl.
Lin.ft. Sq.fl.
Lin.fl.
Lin.fl.
Lin ft.
ce
J
Sq.ft
S ft.
uare
d Insulating cement
L Trowel/Sprayer coatings
h.Transite board,wall board
I.Other,please specify.
Lin.ft. Sq.ft
300
Lin.ft. Sq.fl.
Lin.fl. Sq-ft.
1800
Lin.fl. Sq.ft.
TILE& MASTIC
Sq.ft I.Specify
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 OCT-
c.Date(mmldd/yyyy)of Authorization
N/A
e.Name of DOS Official
g.Date(mntldd/yyyy)of Authorization
b.Title
d DEP Waiver
t DOS Official Title
h.DOS Waiver#
o 17. Do prevailing wage rates as per M.G.L. c. 149, §26,27 or 27A—F apply to this project? Lit Yes❑No
o B. Facility Description
o 1. Current or prior use of facility:
0
OFFICE SPACE
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes 0 No
3.
0
0
Z
MASSACHUSETTS HIGHWAY DEPARTMEN
a.Facility Owner Name
NORTHAMPTON
c City/Town
KRISTEN WELLS
01060
d Zip Code
4' a.Name of Facility Owner's On-Site Manager
anf001ap doc•10/02
c.City/Town
d,Zip Code
811 NORTH KING STREET
b.Address
413-582-0523
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 of 3 Ill
1ACCUTECH INSULATION &CONTRACTING 1
a.Name of Trans otter
LUDLOW
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
7.MR 19.000
rt
° D. Certification
/,►
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100079164
Decal Number
B. Facility Description (cont.)
5.
[BURKE CONSTRUCTION
a Name of General Contractor
ADAMS
c.City/Town
!COMMERCE&INDUSTRY
I.Contractor's Workers Comp.Insurer
6. What is the size of this facility?
01220
d.Zip Code
16 RENFREW STREET
b Address
1413-743-3065
e.Telephone Number(area code and extension)
1 W C5312904 1 111/04/2008
q.Policy Number h.Exp.Date(mnydd/yyyy)
130,000 1 12 !
a.Square Feet b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
H 101056 1
c.City/Town d.Zip Code
1100 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
c.City/Town
3. 1
106480
d.Zip Code
a.Refuse Transfer Station and Owner
1173 PICKERING STREET
b.Address
1(860) 342-1022
e.Telephone Number
c.City/Town
4 !MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
19000 MINERVA ROAD
C.Final Disposal Site Address
10M
State
e.S
d.Zip Code
b.Address
e Telephone Number
144688
L Zip Code
b.Final Disposal Site Location Owners Name
!WAYNESBURG
d City/Town
g Telephone Number
The undersigned hereby states, under the
° penalties of perjury, that he/she has read the
Co o Ith f Ma ch tt eg I t
for the Removal, Containment or
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15,and that the information
t ed the tficat 'st do t
to the best of his/her knowledge and belief.
0
0
Z
anf001ap doc•10/02
!HEATHER R.CREPEAU [
a.Name
!ADMIN.ASSISTANT 1
c.Position/Titl
1(413) 583-5500
e.Telephone Number
1100 STATE STREET
q.Address
LUDLOW
It City/Town
b.Autho
zed
ature
09/30/2008
d.Date(mm/dd/vwV)
1ACCUTECH
Representing
101056
Zip Code
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Asbestos Notification Form•Page 3 of 3 1.
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