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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100049312
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? t7 Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
WILL WEBBER RESIDENCE
a.Name of Facilit
NORTHAMPTON
C.City/Town
3. Worksite Location:
action of this
/st be
led in order
ay with 4
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vents of 310
15 5
Division
!pational
DOS)
ion
rents of 453
12
o
BASEMENT
a.Building Name/Building Location
Is the facility occupied?
Asbestos Contractor:
Fl
MA
d.State
b.Building#
Yes ❑No
Blanket Decal Number
68-70 CONZ STREET
ACCUTECH INSULATION &CONTRACTING S
a Name
LUDLOW
C City/Town
01056
d.Zip Code
AC000005
f.DOS License Number
b.Street Address
01060
e.Zip Code
C.Wing
(413)584-1852
f.Telephone Number
d.Floor
e Room
100 STATE STREET
b.Address
4135835500
e.Telephone Number
g. Contract Type: ❑Written
❑Verbal
h.Facility Contact Person
DALE A HARDY
6' a.Name of On-Site Supervisor/Foreman
T a.Name of Project Monitor
ATC
SCILAB
8' a.Name of Asbestos Analytical Lab
9 a.Project Start Date(mm/ddlyyyy)
12/15/2006
8:004:30
c.Work hours Mon-Fri.
o 10. a. That type of project is this?
_o
❑Demolition Fl Renovation
❑Repair ❑Other, please specify:
11. a. Check abatement procedures:
o ❑Glove bag
o ❑Enclosure
Cleanup
Full containment
Z
t7
0
• 12. Is the job being conducted:
IOtap.doc•10/02
i.Contact Person's Title
AS071733
b.Supervisor/Foreman DOS Certification Number
AA000005
b.Project Monitor DOS Certification Number
AA000162
b.Asbestos Analytical Lab DOS Certification Number
12/19/2006
b.End Date(mm/dd/yyyy)
N/A
d-Work hours SatSun-
b.Describe
❑ Encapsulation
❑Disposal only
❑Other, specify:
b.--Describe
(7
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Asbestos Notification Form•Page 1 of 3 U
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100049312
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed,enclosed, or
encapsulated:
270
a.Total pipes or ducts(Near ft)
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
32
b. l otal other surfaces(square ft)
Lin.ft.
20
Lin.ft.
Lin.ft.
Lin.ft
Lin.ft,
30
Sq.ft.
Sq.ft.
Sq.ft.
d.Insulating cement
1.Trowel/Sprayer coatings
h.Transite board,wall board
1.Other.please specify.
IREWET PIPES
Sq. _ I.Specify
14. Describe the decontamination system(s)to be used:
Lin.ft
Lin.ft.
Lin.ft
2
Sq.ft.
Sq.ft.
1250
Lin.ft.
Sq.ft.
TWO LAYERS OF 6 MIL POLY ON THE WALLS AND FLOOR WITH AN ATTACHED 3 STAGE DE
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:
'BRIAN BOURDEAUX
a.Name of DEP Official
12/14/2006
F.Date(mmlddfyyyy)of Authorization
EVELYN CORRERA
e,Name of DOS Official
12/14/2006
9.Date(mmlddlyyyy)of Authorization
b.True
W343-06
d.DEP Waiver#
f.DOS Official Title
06-475-NB
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 SI No
—° B. Facility Description
o 1. Current or prior use of facility:
0
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Z
RESIDENCE
2. Is the facility owner-occupied residential with 4 units or less?
3,
WILL WEBBER
a.Facility Owner Name
NORTHAMPTON
c.City/Town
01060
d.Zip code
WILL WEBBER
a.Name of Facility Owner's On-Site Manager
c c.City/Town
01 ap.doc•10/02
d.Zip Code
Yes 7 No
68-70 CONZ STREET
b.Address
413-564-1852
e.Telephone Number area code and extension
b.On-Site Manager Addre
e.Telephone Number(area code and extension)
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100049312
Decal Number
B. Facility Description (cont.)
N/A
5- a.Name of General Contractor
c.City/Town
d.Zip Code
GRANITE STATE
f.Contractors Worker's Comp.Insurer
6. What is the size of this facility?
b.Address
e.Telephone Number(area cod and extension)
WC5310868
q.Policy Number
3000
a.Square Feet
11/04/2007
h.Exp.Date(mm/dd/yyyy)
2
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
ACCUTECH INSULATION 8 CONTRACTING
a.Name of Transporter
!LUDLOW
c.CityffoVn
01056
100 STATE ST. P.O.BOX 376
b.Address
(413) 583-5500
d.Zip Code e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
3
4
RED TECHNOLOGIES, LLC
a Name of Transporter
BLOOMFIELD
c.City/Town
06002
a Zip Code
a.Refuse Transfer Station and Owner
c.City/Town
d Zip Code
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
OH
e.State
44688
f.Zip Code
10 NORTHWOOD DRIVE
b.Address
(860)218.2428
e.Telephone Number
b.Address
e.Telephone Number
b.Final Disposal Site Location Owner's Name
WAYNESBURG
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
f th R o al C t ' nt or
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15, and that the information
ntained in this notification is true and correct
t the best of his/her knowledge and belief.
01ap.doc•10/02
JUDY CROWLEY
a.Name
OFFICE MANAGER
c.Position/Title
(413) 583.5500
e.Telephone Number
ed Signature
006
d Date(mmlddNVVV)
ACCUTECH
f.Representing
100 STATE ST. P.O.BOX 376
q.Address
LUDLOW
h.City/Town
01056
Zip Code
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Asbestos Notification Form•Page 3 of 3 U