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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
[RUCTIONS
Description
a.Is this facility fee exempt-cry•^Yes L✓�No of four units or less L
Blanket Decal Number
P. Provide blanket decal number if applicable A. Asbestos Abatement
00071600
Decal Number
district municipal housing authority, owner-occupied
1.
2. Facility Location: _.
CLARK AVENUE CONDOMINIUM ASSOC
NORTHAMPTON _—"MA
tate
.City[ o
3, Worksite Location:
BASEMENT
11 sections of this
r must a.Building Name/Building Location
st occupied? ,-•.
'b Building
Yes No
ipleted in order 4 Is the facility
omply with
P notification
uo-emams of 3105 Asbestos Contractor:
------
I53CLARK AVENUE _�
b.5reet Atltless _ -.
'. 413) 734-5751
(010p0 rI f_
e.Zip Code f.Telephone Number
f -
_J
d Floor e.Room
c.Wing
he Division
Occupational
•ey(DOS)
tficaton
qu rements of 453
NR 6.12
tACCUTEC__H INSULATION 8 CONTRACTING I —
a.Name r 01056 14135835500 __--
'LUDLOW OW –_--_� e Telephone Number
O Zip Code !,Verbal
C.Ci (Town --- ;'Written
,AC000005 _ g. Contract TYPe
t DOS License Nember _ le-
'riun FR
h .100 STATE STREET
p Address
___________________I '413 734-5751 ----I
Contact_Persons — I
AS073309
S C rt f¢a ion Number
AA000005
_ 1 b.Protect Monitor DOS Certiiickon Number _
AA000162
b ASbes.tos analvtcal Lai D_O_-SCertification Number
0512012008 ----
d PO Pate Immlddimy) —
_ NIA _ _ __ _
d.Work hours-Sal Sun
h. Contact Ira or _ ___----
6 STEVE TAVERNIER
a.Name of On-Site SogervisorlFO eman
7.
a.Name fP olect Monitor
p SupervisorlFprema DO _e j
ISCILAB - --
8_ a.Name of Asbesto a Anaical Lao _
'0511912008
o 9_ a.P!pjact Statl Daie(m_rnlJtllyyyyl_ _-.
O 7:00-5:00
_.__.__
__
c.Work hours Mon-Fn.
N
O 10 a.What type of project is this?
Demolition J. Renovation
pO — -' Other.please specify'.
^''..Repair �--
• 11.• a Check abatement procedures:
O
u.
1 Glove bag Encapsulation
[D Enclosure Disposal only
;J Cleanup
I Other, specify'.
LI Full containment Outdoors?
12. Is the job being conducted: 'JI Indoors? �_
an1001 ap doc•10102
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100071600
'Decal Number
0
0
N
a
0
0
0
LL
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
10 J
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
400
I
su aces square ftjj
1 I
_ ' d Insulating cement
Lin ft Sq.fi__
x,400 I f.Trowel/Sprayer coatings
L in.ft. "§q ft
_ t_ -- h.Transite board,wall board
L in.ft Sq.ft.
—.—
l— —1 i,Other,please specify:
k.Thermal,solid core pipe r-
_ _ J I.Specify
insulation Lin.fl. Sq
1 1 i— i
Lin.ft. Sq.ft.
1I
Lin.ft. Sq.ft.
Lin_ q.ft
J
Lin.ft _ Sq.f1.�
_J
14. Describe the decontamination system(s)to be used:
SEAL OFF THE AREA USING BARRIER TAPE.WET DOWN THE ACM WITH AMENDED WATER
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
IACM 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:.
NIA
a.Name of D�rOTiicia ___ _ — —1
_--_
c.Date mmltltll )of Authorization ▪ d.DEP waiver#
.N/A -- 7DO5 oefa ati
-- 1 tle
e.Name of DOS Official -- ---
gate(mMtltllyyyy)—f lhonzeton J 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 T No
B. Facility Description
CONDOMINIUMS
1 Current or prior use of facility. --
J
2. Is the facility owner-occupied residential with 4 units or less? Yes ! No _.
73 MAIN STREET
3 ,EAGLE CREST PR O PERT Y MA G
NAEMENT_
a.Facirty Owner Name_
1IAMHERST '01002
C.Ciy%TOWn______ _ tl Zip Code _
4 ,GREG NEFFINGER _
a.Name of Facility Owners On 51e Manager__ ___
anfOOlap.doc•10102
c.City/Town
1..413-734-5751 _I
e Telephone Number(area code and extension) __
b On-Site Manager Address
.413-734-5751 __—•
e.Telephone Number(area cotle antl extension)
Asbestos Notification Fom•Pa ea a 2
Note-:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
Decal Number
B. Facility Description (cont.)
5.
N/A
a.Name of General Contractor
c.City/Town
COMMERCE& INDUSTRY
C Contractors Workers Camp. Insurer
What is the size of this facility?
b.Address
d Zip Code
e.Telephone Number(area code and extension)
IWC5312904 7 [11104/2008
,q Policy Number Exp. Date(mrtWd/yyyy),_
I
�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):
ACCUTECH INSULATION &CONTRACTING i
a.Name of Transporter
ItLUDLOW j .01056
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:
3
BRED TECHNOLOGIES
a.Name of Transporter
(PORTLAND j !0_6480_
C.City/Town dijp Code
a Refuse Transfer Station and Owner
'.173 PICKERING STREET
b.Address
1(860)342-1022
e.Telephone Number
b.Address
c.City/Town d.Zip Code
4. !MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
:OH '.:44688
..___o___._,..
e.
State i.Zip Code
e.Telephone Number
b Final Disposal Site Location Owners Name_
WAYNESBURG j
d.City/Town
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
tained in this notification is true and correct
° to the best of his/her knowledge and belief.
0
2
C
ant001ap.doc•10/02
TRACY E. PAS
a.Name •-Authoriz'• SirZature
ADMIN ASSISTANT '05/05/2008
c.Position/Tale 0.Date rnm!dd/yyyv)
(413) 583-5500 _ '.A000TECH
e Telepone Number f Representirx,L
000 STATE STREET
,g.Address __
LUDLOW
01056 —--- I
h.City/Town i.Zip Code
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Asbestos Notification Form•Page 3 of 3 •