58 Asbestos Notification Form 2008 ...._.. __..j
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Asbestos Contractor:
(ACE ASBESTOS REMOVAL AND INSULATIO 1
a.Name
'NORTHFIELD
c.City/Town
IAC000006
f. DOS License Number
Important:
When filling out
fors on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key_
INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
1100073957
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 less9 14 Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
IROULEAU RESIDENCE
a.Name of Facili
'Northampton
c City/Town
3. Worksite Location:
1.All sections of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR715 5.
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 612
'BASEMENT
a Building Name adding Location
MA
State
b.Building#
Is the facility occupied? • Yes ❑ No
01360
d Zip Code
'THOMAS R SHEARER
h.Facility Contact Person
'THOMAS R SHEARER
6. a Name of On-Site Supervisor/Foreman
(RAYMOND BRESNAHAN
a.Name of Project Monitor
'ENVIRONMENTAL SAMPLING 8 TESTING
6' a.Name of Asbestos Analytical Lab
9 r7!1 012008
a.Project Start bete(mm/ddlyyyy)
7-5PM
c.Work hours Mon-Fn.
10. a. What type of project is this?
0 ❑ Demolition 0 Renovation
❑ Repair ❑Other, please specify:
11. a. Check abatement procedures:
pJ Glove bag ❑ Encapsulation
Enclosure ❑ Disposal only
Cleanup ❑ Other, specify:
a Full containment
0
12. Is the job being conducted:
anf001 ap doe•10/02
Blanket Decal Number
158 COLUMBUS AVE
b.Street Address
01060
e.Zip Code
c.Wing
4135846362
i.Telephone Number
d. Floor
e. Room
716 PINE MEADOW ROAD
b.Address
14134980201
e.Telephone Number
g. Contract Type: IS Written ' ❑Verbal
'SUPERVISOR
I.Contact Person's Title
(AS070066
b.Supervisor/Foreman DOS Certification Number
IAM900294
b.Project Monitor DOS Certification Number
1.AA000132
b.Asbestos Analytical Lab DOS Certification Number
17i16:200S
b nd Date(mm/ddl yyyy)
(NA
d.Walk hours Sat-Sun.
Indoors? ❑Outdoors?
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Commonwealth - Massachusetts
Asbestos Notification Form ANF-001
•
100073957
Decal Number
A. Asbestos Abatement Description (cont )
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or
encapsulated:
200
a Total pipes or ducts(linear ft)
c.Boiler,breathing,dud,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
0
b.Total other surfaces(square ft)
200
Lin.ft
Lin.ft.
Sq.ft.
Sq.ft.
tin.ft. Sq.ft.
d.Insulating cement
f Trowel/Sprayer coatings
h.Transite board,wall board
Lin. . I.Other,please specify:
Lin.ft.
14. Describe the decontamination system(s)to be used:
I.Specify
Lin.ft.
tin.ft
Sq.ft
Sq.ft
Lin.ft.
n. Sq.
THREE CHAMBER DECON WITH WARM WATER SHOWER,TYVEK SUITS, HEPA VAC
15. Describe the containerization/disposal methods to comply with 3W CMR 7.15 and 453 CMR
6.14(2) (g):
REWET ASBESTOS AND PACK IN DOUBLE, LABLED AND SEALED BAGS
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a.Name of utv Onicie
c.Date(mridd/yyyy)of Authorization n
e.Name of DOS Ofidal
g.Date(mm/dd/yyyy)of Authorization
d. DEP Waiver
f DOS Official Title
h.DOS Waiver#
17. Do prevailing wage rates as per M.G.L. c. 149,§26,27 or 27A—F apply to this project? ❑Yes • No
B. Facility Description
0
111•11111MMo
LL 4 NA
Z
Q c City/Town
anf001ap.doc•10/02
Current or prior use of facility:
RESIDENTIAL
Is the facility owner-occupied residential with 4 units or less?
JANE AND GEORGIANNA ROULEAU
a.Facility Owner Name
NORTHAMPTON
c.City/Town
01060
d.Zip Code
a.Name of Facility Owner's On-Site Manager
d.Zip Code
Yes ❑ No
58 COLUMBUS AVE
b.Address
4133648362
e.Telephone Number(area code and extension)
b.On-Site Manager Address
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3
•
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
m
a
N
Z
r ,
Commonwealth o. .Aassachusetts
Asbestos Notification Form ANF-001
1100073957
Decal Number
B. Facility Description (cont.)
ACE ASBESTOS REMOVAL&INSULATION
5' a. Name of General Contractor
NORTHFIELD
c.City/Town
01360
d.Zip Code
GRANITE STATE INS.CO.
f.Contractors Workers Comp.Insurer
6. What is the size of this facility?
101 CROSS RD
b.Address
413-498-0201
e.Telephone Number(area code and extension)
9/1/2008
h.Exp_Date(mm/dd/yyyy)
WC6381497
g.Policy Number
2500
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):
'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:
1TRANSWASTE INC. 3 BARKER DRIVE
a.Name of Transporter b.Address
'WALLINGFORD 2032698300
c.City/Town d Zip Code e Telephone Number
3. NA
a.Refuse Transfer Station arid Owner b.Address
4
C.Ciy/Town
06492
d.Zlp Code
BFI IMPERIAL LANDFILL
a.Final Disposal Site Location Name
PO BOX 47-11 BOGGS ROAD
c.Final Disposal Site Address
1
PA
e.State
15126
L Zip Code
e.Telephone Number
(BROWNING FERRIS INDUSTRIES
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 the
Commonwealth of Massachusetts regulations
f th R I C ta' m t
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.
• anf001ap.doc•10/02
THOMAS R. SHEARER
a.Name
PRESIDENT
c.Positionmtle
4134980201
e.Telephone Number
1413498-0201
q.Address
NORTHFIELD
H.City/Town
Thomas R. Shearer
b.Authorized Signature
06/20/2008
d. Date(mm/ddtyyyv)
ACE ASBESTOS REMOV
f.Representing .
J
01360
1
i.Zip Code
Asbestos Notification Form•Page 3 of 3 II