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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
■
100081017
Decal Number
A. Asbestos Abatement Description
a. Is this facility fee exempt-city,town,district,municipal housing authority,owner-occupied
residence of four units or less? 17 Yes ❑No
b. Provide blanket decal number if applicable:
TRUCTI ONS
.11 sections of this
must be a.Building Name/Building Location
Ipleted in order
2. Facility Location:
VA MEDICAL CENTER
a.Name of Facility
(NORTHAMPTON
c.City/Town
3. Worksite Location:
VA MEDICAL CENTER
amply with 4.
notification
ments of 310
i715 5.
the Division
ccupational
ity(DOS)
canon
arements or453
6.12
0
0
0
LL
6.
Is the facility occupied?
Asbestos Contractor:
MA
d.State
6826
b.Building&
Yes ❑No
ING ENVIRONMENTAL CONTRACTORS LLC
a.Name
LAWRENCE
c.City/Town
AC000631
f DOS License Number
01843
d.Zip Code
h.Facility Contact Person
NOLBERTO GALICIA
a.Name of On-Site SupeivisorlForeman
7 INTERNATIONAL ENGINNERING GROUP, IN
a.Name of Project Monitor
'INTERNATIONAL ENGINNERING GROUP, IN 1
a.Name of Asbestos Analytical Lab
9 112/01/2008
.P 1 t Start Date(mMddtyyyy)
7-4
c.Work hours Mon-Fri.
10 a What type of project is this?
❑ Demolition N Renovation
❑ Repair ❑ Other,please specify:
11. a. Check abatement procedures:
❑Glove bag
❑Enclosure
❑Cleanup
Full containment
4 12. Is the job being conducted:
nt001 ap.doc•10/02
❑ Encapsulation
❑Disposal only
❑ Other, specify:
17
Blanket Decal Number
421 N.MAIN STREET
b.Street Address
01053
e.Zip Code
c.Wing
(413)584-4040
f.Telephone Number
1 8 CRAWL
d.Floor
'BATHROOM
e.Room
49 BLANCHARD STREET SUITE 202
b-Address
9787947922
e.Telephone Number
g. Contract Type:
t7
Written ❑Verbal
i.Contact Person's Title
AS052665
b.Supervisor/Foreman DOS Certification Number
1AM030636
b.Project Monitor DOS Certification Number
1AA000135
b.Asbestos Analytical Lab DOS Codification Number
h 2/12/2008
b.End Date(mm/ddtyyyy)
1N/A
d.Work hours Sat-Sun.
b.Describe
b.Describe
Indoors? ❑Outdoors?
Asbestos Notification Form•Page 1 of 3
Commonwealth of Massachusetts
IAsbestos Notification Form ANF-001
•
100081017
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or
encapsulated:
496
a.Total pipes or ducts(linear ft)
c.Boiler,breathing,duct,tank
surface coatings
e.Gonugated or layered paper
pipe insulation
g.Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
12000
b.Total other sudaces(square ft)
d.Insulating cement
f.Trowel/Sprayer coatings
h Transite board,wall board
j.Other,please specify:
Lin.ft. Sq.ft.
Lin.ft
Sq.ft
Lin.ft. sq.ft.
Dn.ft.
496
Lin.ft.
14. Describe the decontamination system(s)to be used:
Lin.ft.
Lin.ft.
Sq.ft.
ISq.ft.
Lin.ft. S9.rt
2000
Lin. . Sq.ft.
DEBRIS&SOIL
Speafy
3 CHAMBERS DECONTAMINATION SYSTEM
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
DOUBLE BAG SEALED AND LABELED
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
11
b.Tge
N/A
a.Name of DEP Official
c.Date(mm/dd/yyyy)of Audmnzation
e.Name of DOS Official
g Date(mm/dd/yyyy)of Authorization
d.DEP Waiver*
C DOS Official Ttlle
h.DOS Waiver#
17. Do prevailing wage rates as per M.G.L. c. 149,§26, 27 or 27A—F apply to this project? p Yes❑No
° B. Facility Description
1 C rrent or prior use of facility:
MEDICAL CENTER
2. Is the facility owner-occupied residential with 4 units or less?
3. a.Facility Owner Name
0
VETERANS ADMINISTRATION MEDICAL CE
NORTHAMPTHON MA
c.City/Town
4. IN/A
a.Name of Facility Owner's On-Site Manager
01053
d.Zip Code
rnf001ap.doc•10/02
c.City/Town
d.Zip Code
12
Yes ❑No
421 N. MAIN STREET
b.Address
413-584-4040
e.Telephone Number(area code and extension)
1
b.On-Site Manager Address
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa ea a 2
Commonwealth of Massachusetts
L Asbestos Notification Form ANF-001
Transfer
ons must
ply with the
i Waste
;ion
ulations 310
19.000
100081017
Decal Number
B. Facility Description (cont.)
5
B&J MULTISERVICE CORPORATION
a.Name of General Contractor
LEOMINISTER MA
c.City/Town
01453
d.Zip Code
f.Contractor's Workers Comp.Insurer
6. What is the size of this facility?
18 ALLEN STREET
b.Address
978-534-6306
e.Telephone Number(area code and extension)
I I
g.Policy Number
170000
a.Square Feet
h. Exp.Date(mm/dd/yyyy)
[3
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
NG ENVIRONMENTAL CONTRACTORS, LLC
a.Name of Transporter
LAWRENCE MA
c.City/Town
01843
d.Zip Code
49 BLANCHARD STREET
b.Address
(978)794-7922
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
SERVICES TRANSPORT GROUP
a.Name of Transporter
INEW CASTLE DE
c.City/Town
3. IN/A
a.Refuse Transfer Station and Owner
19720
d.Zip Code
c.City/Town
4. IA&L SALVAGE INC
a.Final Disposal Site Location Name
F11225 STATE ROUTE 45
c.Final Disposal Site Address
10H
e.State
d.Zip Code
168 PYLES LN
b.Address
(877)999-9559
e.Telephone Number
b.Address
e.Telephone Number
b.Final Disposal Site Location Owner's Name
I 'LISBON
d.City/Town
44432
f.Zip Code
g.Telephone Number
° D. Certification
The undersigned hereby states,under the
p Iti f perjury,that he/she has read the
C Ith f M ch tt g I t
for the Removal,Containment or
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15, and that the information
t ' d' th' tf f ' t doorect
° t th b t f h- /h k wledg db T f
0
z
mf001ap.doc•10/02
NOLBERTO GALICIA
a.Name
PRESIDENT
c.PositionTlle
(978)794-7922
e.Telephone Number
149 BLANCHARD STREET
g Address
'LAWRENCE MA
b.City/Town
b.Authorized Signature
d.Date(mm/dd/yyyy)
ING ENVIRONMENTAL
f.Representing
01843
i.Zip Code
Go To Top
Asbestos Notification Form•Page 3 of 3 II
I Massachusetts Department of Environmental Protection
Bureau of Waste Prevention • Air Quality
BWP AQ 06
tent:
filling out
an the
iter,use
re tab key
re your
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e return
Notification Prior to Construction or Demolition
100081023
Decal Number
A. Applicability
A Construction or Demolition operation of an industrial,commercial, or institutional building,or
residential building with 20 or more units is regulated by the Department of Environmental Protection
(DEP), Bureau of Waste Prevention-Air Quality Control Regulations 310 CMR 7.09. Notification of
Construction or Demolition operations is required under 310 CMR 7.09(2)ten(10) days prior to any
work being performed.The following information is required pursuant to 310 CMR 7.09.
B. General Project Description
1. a. Is this facility fee exempt-city,town, district, municipal housing authority,owner-occupied
coons residence of four units or less? t7 Yes ❑No
sections of
rm must be
order
ply with the
2. Facility Information:
p y
tmeet of
:tlon
on al
a
ameamen0 of
MR].09
b. Provide blanket decal number if applicable:
0
0
N
0
Blanket Decal Number
VA MEDICAL CENTER
a.Name
421 N. MAIN STREET
b.Address
NORTHAMPTON
c.City/Town
4135844040
f Telephone Number larea code and extension)
7000
h.Size of Facility in Square Feet
MA
01053
d.State e.Zip Code
Inolberto12002@yahoo.com
g.E-mail Address(optional)
13
Number of Floors
j. Was the facility built prior to 1980? 0 Yes ❑ No
k. Describe the current or prior use of the facility:
MEDICAL CENTER
I. Is the facility a residential facility? ❑ Yes NI No
m. If yes, how many units?
3 Facility Owner:
Number of Units
VETERANS ADMINSTRATION MEDICAL CENTER
a.Name
421 N.MAIN STREET
b.Address
NORTHAMPTON
m c.City/Town
4135844040
f Telephone Number(area code and extension)
D
C
MA
d.State
01053
e.Zio Code
E-mail Address foolionah
h Onsile Manager Name
106.doc•10/02
BWP AD 06•Page l of 3�
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention •Air Quality
BWP AQ 06
Notification Prior to Construction or Demolition
1100081023
Decal Number
)5 is If found
a is
3
fiction or
onn
si all
amyl pwith
AR 7.00.
.1 ,and
s
121E aw
.r of
Laws of of
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nmonwealth.
quid include.
old not be ge
to, moval
filing al an
ion with the
m en(and/or
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sofa
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nce to the
bent,,if
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N
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O
O
B. General Project Description (cont.)
4. General Contractor:
1B S J MULTISERVICE CORPORATION
a.Name
18 ALLEN STREET
O.Address
ILEOMINISTER
c.City/Town
9785346306
f.Telephone Number area code and extension)
1BOB GIFFORD
h.On-site Manager Name
MA
01453
d State e Zip Code
IBJmultiservice-Bob @verizon.net
o.E-mail Address(optional)
C. General Construction or Demolition Description
1. Construction or demolition contractor:
NG ENVIRONMENTAL CONTRACTORS LLC
a.Name
149 BLANCHARD STREET
b.Address
'LAWRENCE
c.City/Town
9787947922
f Telephone Number(area code and extension)
MA
01843
d.State e.Zip Code
(nolberto12002 @yahoo.com
E-mail Address(optional)
STEVEN BUCKNAM
b.On-site Manager Name
2. On-Site Supervisor:
1MIGUEL T BAEZ
4
5
q06 doc•10(02
On-Site Supervisor Name
Is the entire facility to be demolished? ❑ Yes
Describe the area(s)to be demolished
O
No
BATHROOMS
If this is a construction project, describe the building(s)or addition(s)to be constructed:
BATHROOMS RENOVATIONS
BWP AO 06•Page 2 of 3•
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention •Air Quality
BWP AQ 06
Notification Prior to Construction or Demolition
•
1100081023
Decal Number
C. General Construction or Demolition Description (cont.)
6. a. If this is a demolition project,were the structure(s)surveyed for the presence of asbestos
containing material (ACM)?
Yes ❑ No
If yes,who conducted the survey?
ATC(DEREK WISMAN)
b.Surveyor Name
AA000005
c.Division of Occupational Safety Certification Number
7. Construction or Demolition:
12/1/2008
a.Start Date(mmlddtyyyy)
112/19/2008
b.End Date(mMddlyyyy)
8. a. For demolition and construction projects, indicate dust suppression techniques to be used:
seeding ❑ paving
❑ wetting ❑ shrouding
covering 0 other
b. If other, please specify:
CONTAINMENT NEGATIVE PRESSURE
9. For Emergency Demolition Operations,who is the DEP official who evaluated the emergency?
N/A
a.Name of DEP Officia
b.Title
c.Date(mrr dd/yyyy)of Authorization
d DEP Waiver Number
D. Certification
I certify that I have examined the
above and that to the best of my
knowledge it is true and complete.
The signature below subjects the
signer to the general statutes
o regarding a false and misleading
statement(s).
0
a
06.doc•10/02
NOLBERTO GALICIA
a.Print Name
NOLBERTO GALICIA
b.Authorized Signature
PRESIDENT
INC ENVIRONMENTAL CONTRACTORS, LLC
d.Representing
11106/2008
e.Date(mmldd/yyyy)
BWP AP 06•Page 3 of 3�
Asbestos • Lead Paint Removal • Select Demolition
11/06/2008
Dear Sir/Madam
Public Health Department
23 Service Center Rd,
Northampton Ma 01060
Enclosed you will find a copy of the Asbestos abatement Notification send to the
Department of Environmental Protection, for the job at VA Medical Center, 421 N. Main
Street, Northampton Ma 01053.
Any questions please feel free to call me at 978-794-7922
Sincerely,
Nolberto Galicia
NO Environmental Contractors, LLC
49 Blanchard Street • Suite 107 • Lawrence. MA or8c3
Tel: 978-796-7922 • Fax: 978-79a 7929 • www n,4envi ronmenla[.co'n