27 Asbestos Notification Form 2008 I
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Commonwealth .^Massachusetts
Asbestos Notification Form ANF-001
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? fl Yes ❑No
b.Provide blanket decal number if applicable:
2. Facility Location.
3TRUCTIONS
All sections of this
m must be
impleted in order
comply with 4.
EP notification
puirements of 310 5
MR 7.15
nd the Division
f Occupational
,efety(DOS)
otification
epuirements of 453
;MR 6.12
Blanket Decal Number
BLACK RESIDENCE
a Na N of
Northampton
c.City/Town
3. Worksite Location:
BASEMENT
a.Building Name/Building Location
mEgM
ry
o
o
anfW lap doc
r
Is the facility occupied?
Asbestos Contractor
MA
d.Sate
b.Street Add
01060
e.Zip Code f.Telephone Number
b.Building#
Yes ❑No
c.Wing
d.Floor
e Room
6.
7.
8.
9.
e.cirt=
AC000006
f. OS icense Number
TOM SHEARER
ad' Contact Person
THOMAS R SHEARER
a N of On-Site�
RAYMOND BRESNAHAN
a.Name of Pm
ENVIRONMENTAL SAMPLING AND TESTING
Name of .
812012008
a.Pro act rt to mml
75PM
c.Work hours on-Fn.
10. a.What type of project is this?
Renovation
o Repair Retion Ti Other,please specify:
11. a.Check abatement p ocedures:
0 Glove bag ❑Encapsulation
Disposal only
❑Cleanup re
❑Enclosure 0 Other,specify:
Full containment
12. Is the job being conducted:
•10102
e.Telephone Number
g. Contract Type: p Written ❑Verbal
SUPERVISOR
I.Contact Person's Title
AS070066 Number
b.Su rvisor/Foreman DOS CeNfi h
AM900294
b.Pro ect Monitor DOS Cedification Number
AA000132
An Lab D S Certification Number
mml ddl
brk Hours al-Sun.
b.Asbestos
812212008
b.E nd Date
NA
b.Describe
b.Describe
Indoors? ❑Outdoors?
ECEAVIE
AUG - ) 1008
NORTHAMPTON BOARD OF HEALTH
Asbestos Notification Form•Page 1 of 3 I
Commonwealth G. Massachusetts
Asbestos Notification Form ANF-001
v
100075484
cal
um er
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or
enca•sulated:
0
a. ota p pea or
er su aoes square
d.Insulating cement
f.Trowel/Sprayer coatings
h.Transite board,wall board
C.Boiler,breathing,duct,tank
surface coatings
e.Corrugated a layered paper
pipe Insulation
g.Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
Insulation
14. Describe the decontamination system(s)to be used: 7EK SUBS AND HEPA VAC
THREE CHAMBER DECON WITH WARM SHOWER, ri
15. Describe the mntainelization(disposal methods to comply with 310 CMR 7.15 and 453 CMR
Lin.ft.
).Other,please a
U Sct
Sq ft.
in ft.
in.
•
6.14(2)(!):
REWET ASBESTOS AND PACK IN DOUBLE, IABLED AND SEALED POLY BAGS
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
a. erne
at Loa
c.Date mmidd/ )e o ration
e. ame nee
g.Data(m dwnrzation
17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? 0 Yes O No
• •'.. o
elver
B. Facility Description
1. Current or prior use of facility:
2. Is the facility owneroccupied residential with 4 units or less? Yes 0 No
BARBARA BLACK 2727 NORTHERN AVE.
3• b.Address
a.Fad li Owner Name --
413-586-6671 01060
ex
e.Tale• one Number area code and tens on
RESIDENCE
l7
NORTHAMPTON
Code
4. a.Name o t Fadl'ty Owners On de
a Clty/Town
■ anloofap.doc•10IO2
anger
b.On-Site Mana,or Address
d.zip Code
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3 1
Note:Transfer
Stations must
comply wih the
Solid Waste
Division
Regulations 310
CMR 19.000
re
O
EFEEE0
0
MEM
0
MME0
oak
Commonwealth c. Massachusetts
Asbestos Notification Form ANF-001
1100075464
Decal Number
B. Facility Description (cont.)
ACE ASBESTOS REMOVAL&INSULATION
5. a.Name of General Contractor
NORTHFIELD
c.City/Town
IGRANIT STATE
f.Conhactafs Worker's Comp.Insurer
6. What is the size of this facility?
01360
d.Zip Code
101 CROSS RD.
b.Address
413-498-0201
a.Telephone Number(area code and extension)
191112008
h. Exp.Date(mm/dd/yyyy)
I la
b.Number of floors
(WC4398654
g.Policy Number
11800
a.Square Feet
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site (if necessary):
ACE ASBESTOS REMOVAL&INSULATION
a.Name of Transporter
'NORTHFIELD
c.City/Town
01360
d.Zip Code
101 CROSS RD.
b.Address
4134980201
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
TRANSWASTE INC
a.Name of Transporter
(WALLINGFORD
c.Ciy?own
3. INA
a.Refuse Transfer Station and Owner
06492
d.Zip Code
c.City/Town
4. (BFI IMPERIAL LANDFILL
a.Final Disposal Site Location Name
d.Zip Code
IPO BOX 47-11 BOGGS ROAD
c.Final Disposal Site Address
IPA
e.State
15126
L Zip Code
3 BARKER DRIVE
b.Address
2032898300
e.Telephone Number
I
b.Address
e.Telephone Number
(BROWNING FERRIS IND.
b.Final Disposal Site Location Owner's Name
(IMPERIAL
d.City/Town
(7246950900
g.Telephone Number
D. Certification
The undersigned hereby states, under the
penalties of perjury,that he/she has read he
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
sates IL
WM/lz.
i <
anfOOl ap doc•10/02
THOMAS R.SHEARER
a,Name
(PRESIDENT
c.Position/Title
4134980201
e.Telephone Number
[101 CROSS RD.
q.Address
(NORTHFIELD
h.City/Town
Thomas R. Shearer
b.Authorized Signature
(07/21/2008
d.Date(mm/dd/ywy)
(ACE ASBESTOS REMOVI
f.Representing _
(
01360
i.Zip Code
Asbestos Notification Form•Page 3 of 3