881 Asbestos Notification Form 2008 .•
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
00069701
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 less? f l Yes ❑No
b.Provide blanket decal number if applicable:
2. Facility Location'.
NSTRUOTIONS
I.All sections of this a
form must be
completed in order
to comply with 4. Is the facility occupied?
DEP notification
requirements of 3105 Asbestos Contractor:CMR 7.15
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 612
a.N ameo
NORTHAMPTON
c.ei ynovm
3. Worksite Location:
Blanket Decal Number
.
Building Name/Building Location b Bu
Yes ❑No
6.
7.
8
0
ACCUTECH INSULATION &CONTRACTING I
a
LUDLOW
cc.Di/To/To
AC000005
D.S License Number
JOHN J.BURKE
Facih Contact Person
TYRONE P TILLMAN
a.Name of On-Site Su• rvisor/Foreman
URS
a.Name of Pro ed Monitor
Name of A best besto Ana ical Lab
0610412008
a.Pro et t Start Dale mold
0 17:00.5:00
c.Work hours Mon-Fri.
o 10. a.What type of project is this?
❑Demolition Renovation n
❑Repair ❑ Other, please specify:
11. a. Check abatement procedures:
0 Glove bag r Encapsulation
Enclosure 0 Disposal only
ao
❑Cleanup ❑Other, specify:
b
u` 0 Full containment
12. Is the job being conducted: v Indoors? Outdoo
e Zip Code f.Telephone Number
E=LL] ]
d.Floor e.Room
c.tang
100 STATE STREET
b.Addre
4135835500
01056
d.Zi•code e.Telephone Number
g.Contract Type: Written ❑Verbal
Contact Person's Title
AS071378
b.Su rvisorlForeman DOS C
cation Number
AM061710
b.Pro ect Monitor DOS certification Number
AA000175
b.Asbestos Analytical Lab DOS Certification Numbe
11/08/2008 �----
b.End Date mmlddl
N/A
dWork hours Sat-Sun.
• ant001ap.doc•10/02
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Asbestos Notification Form•Page 1 of 3•
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100069701
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
enca
aDial pores or l s /near
c.Boiler,breaching,duct,tank
surface coatings
e.Corrugated or 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:
SEAL CRITICALS W16MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNIT&INSTALL AIR
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
18500
-57TOB o ers eases square
Lin.ft.
Lin.ft.
NMI
Lin.ft.
Lin.ft.
So.ft.
d.Insulating cement
f.Trowel/Sprayer coatings
h.Transite board wall board
Sc ft.
SL n— j.Other,please speci
[0. VAT/MASTIC
Sq.ft. I.Specify
I
18200
ACM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED
(g):
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
NIA
a. ame
c.Date mm/d of Authonza ion
NIA
e.Name of DOS official
Title
d.DEP Waiver#
pi ✓Scia ire
h DOS Waiver
g.Date(mMtltllyyyy)of Authorization .horization 7 %i Yes"LJ NO
N
0 . prevailing wage rates per M.G.L. c. 149, §26, 27 or 27A—F apply to this project?
B B F. Facility Description
(N
0 1. Current or prior use of facility,
o
2. Is the facility owner-occupied residential with 4 units or less? Z No
MASSACHUSETTS HIGHWAY DEPARTMEN 8I NORTH KING STREET ll
b
(OFFICE SPACE
` 3' a.Facility Owner Name
0
LL
NORTHAMPTON
c.
C tyfT
JOHN J. BURKE
Facili Owner
4. a
z
Name
Q c.City/To
ant001ap.doc•10/02
101060 1413-582-0523
tl ZI Code e.Telephone Number area code and extension)
On-Site Manager
d.Zip Code
Addres
b.On-Site Manager s
413-743-3065
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa a 2
1WAYNESBURG
d.City/Town
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100069701
Decal Number
B. Facility Description (cont.)
c)
0
0
0
IBURKE CONSTRUCTION
5. a.Name of General Contractor
'ADAMS
c.City/Town
!COMMERCE& INDUSTRY
f.Contractors Worker's Camp.Insurer
6. What is the size of this facility?
101220
d.Zip Code
16 RENFREW STREET
b.Address
1413.743-3065
e.Telephone Number(area code and extension)
1 W C l 5312904 111/04/2008
q.Policy Number h.Exp.Date Om/rid/writ
130,000
a.Square Feet b.Number of floors
1 12
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
1ACCUTECH INSULATION &CONTRACTING 1
a.Name of Transporter
'LUDLOW
c.City/Town d.Zip Code e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final dispos
101056
1100 STATE STREET
b.Address
1(413) 583-5500
3
'RED TECHNOLOGIES
a.Name of Transporter
'PORTLAND
c.City/Town
106480
d.Zip Code
a.Refuse Transfer Station and Owner
C.City/Town
4. !MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
19000 MINERVA ROAD
C.Final Disposal Site Address
1OH
e State
d.Zip Code
144688
f Zip Code
1173 PICKERING STREET
al site:
b.Address
1(860) 342-1022
e.Telephone Number
b.Address
e.Telephone Number
b.Final Disposal Site Location Owner's Name
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
contained in this notification is true and correct
to the best of his/her knowledge and belief.
• anfoolap.doc•10/02
HEATHER R.CREPEAU
a.Name
[OFFICE MANAGER 1
c.Position/Title
1(413) 583-5500
e.Telephone Number
1100 STATE STREET
q.Address
'LUDLOW
h.City/Town
b. ignatur e
1103/2612008
d.Date(mm/dd/ww)
14135835500
f.Representing
101056
i.Zip Code
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Asbestos Notification Form•Page 3 of 3•