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Oa. Stik
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100070405
Decal Number
A. Asbestos Abatement Description
1. a. Is this facility fee exempt-cityjown, district, municipal housing authority, owner-occupied
residence of four units or less? Yes EA No
b. Provide blanket decal number if applicable:
2. Facility Location:
RENTAL PROPERTY
a.Name of East
NORTHAMPTON
C.Cityrro
Worksite Location:
BASEMENT b,Building it
a Building Narne/Building Location g
Is the facility occupied? Yes 0 N
INSTRUCTIONS 3.
1.All sections of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR 7.15 5.
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 6.12
0
0
IN
io
IMA
d.State
Asbestos Contractor
ACCUTECH INSULATION
a.Name
LUDLOW
c.
ACM10005
f.DOS License Number
WILL WEBER
h.Facili anted erson
ANTHONY G ROY SR
6. a.Name of On-Site Su ervisor/Foreman
NIA
a.Name of Pro ect Monitor
N/A
a.Name of A Scat Lab
04/21/2008
a.Protect Sta
8:00-5:00
c.Work hours Mon-Fri.
10. a. What type of project is this?
&CONTRACTING I
7.
8.
9.
Blanket Decal Number
14-20 HIGHLAND AVENUE
b.Stree
dress
`01060 I (413) 584-1852
e.Zip Code f.Telephone Number
c.W ng
01056
d.Zi Code
d.Floor
100 STATE STREET
bb.Address
4135835500
e.Telephone Number
e.Room
g. Contract Type: 0 Written ❑Verbal
I.Contact Persons Title
AS071233
b.Su•ervisor/Foreman DOS Certification Number
b.Pro ect Monitor DOS Cedification Number
b.Asbestos Anal ical Lab DOS Certification Number
04/21/2008
b.End Date )
O ❑Demolition ✓: Renovation
ID Repair ❑ Other, please specify:
11. a. Check abatement procedures:
O ❑Glove bag 0 Encapsulation
❑Enclosure ❑ Disposal only
❑Cleanup ❑Other, specify:
u_ ❑Full containment
Z
Q 12. Is the job being conducted: Z Indoors? rI Outdoors?
d.Work hours Sat-Sun.
U anf001apdoc•10102
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Asbestos Notification Form•Page 1 of 3 U
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
1100070405
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed,enclosed, or
encapsulated:
1120
0
a
0
C
a.total pipes or ducts(linear ft)
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
lo
b,Total other surfaces(square ft)
Lin.ft.
Lin.ft
Lin.ft
Lin.ft
120
Lin.ft.
Sq ft
S .ft.
d.Insulating cement
L Trowel/Sprayer coatings
h.Transite board,wall board
j.Other,please specify:
Sq.ft. I. Specify
14. Describe the decontamination system(s)to be used:
'SEAL CRITICALS W/6MIL POLY, PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NEGI
Lin.ft
Lin.ft
Lin.ft.
Sq.ft.
Sq.ft.
Lin.ft.
Sq.ft.
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:
'NIA
a.Name of DEP Official
Ib.Ti
c.Date(mmlddlyyyy)of Authorization
'N/A
e.Name of DOS Official
9.Date(mMtldlyyyy)of Authorization
17. Do prevailing wage rates as per M.G.L. C. 149, §26, 27 or 27A—F apply to this project? ❑Yes ✓ No
d.DEP Waiver#
f.DOS Official Title
II
It DOS Waiver#
B. Facility Description
1 Current or prior use of facility
2. Is the facility owner-occupied
3
WILL WEBER
a.Facility Owner Name
'NORTHAMPTON 101060
c.City/Town d.Zip Code
4. SWILL WEBER
a Name of Facility Owner's On-Site Manager
!RENTAL PROPERTY
residential with 4 units or less? a Yes L! No
anf001ap.doc•10/02
C.City/Town I d.Zip Code
1273 STATE STREET
b.Address
1413-584-1852
e.Telephone Number(area code and extension)
I
b.On-Site Manager Address
1413-584.1852
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa 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
100070405
Decal Number
B. Facility Description (cont.)
5.
N/A
a.Name of General Contractor
(
c.City/Town
(COMMERCE&INDUSTRY
f.Contractor's Workers Comp.Insurer
6. What is the size of this facility?
d.Zip Code
b.Address
e.Telephone Number(area code and extension)
(WC5312904
q.Policy Number
(
a.Square Feet
11/0412008
h.Exp.Date(mm/dd/yyW)
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
a.Name of Transporter
(LUDLOW
c.City/Town d.Zip Code
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
01056
100 STATE STREET
b.Address
(413) 583-5500
e.Telephone Number
3.
4.
!RED TECHNOLOGIES
a.Name of Transporter
PORTLAND
c.Citv/Town
06480
d.Zip Code
a.Refuse Transfer Station and Owner
c.Ciry/Town
d.Zip Code
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
19000 MINERVA ROAD
c.Final Disposal Site Address
(OH
e.State
cJ
0
D. Certification
0
U-
2
C
44688
I.Zip Code
173 PICKERING STREET
b.Address
(860) 342-1022
e.Telephone Number
h.Address
e.Telephone Number
(
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
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.
anf001apdoc•10/02
HEATHER R.CREPEAU
a.Name b.Authorized Signature
'OFFICE MANAGER 1 10410812008 ,
c.Position/Title d D t ( MddArvw)
1(413) 583-5500
e.Telephone Number
100 STATE STREET
q.Address
('LUDLOW 1 101056
h.City/Town i.Zip Code
ACCUTECH
f.Representing
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Asbestos Notification Form•Page 3 of 3 II