202 Asbestos Notification Form 2006 Important:
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INSTRUCTIONS
r
Commonwealth of Massachusetts
a
Asbestos Notification Form ANF-001
100034457
Decal Number
JUN I -9 2006
A. Asbestos Abatement Description 1. a. Is this
facility city municipal housi au
theitIt; i>GOU&Iedmi
residence of four units or less? A Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
1.All sections of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR T.IS 5.
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 612
6
7
B
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N
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C
1TESSA VAN BUSKIRK RESIDENCE
a.Name of Facility
NORTHAMPTON
c.City/Town
Worksite Location:
BASEMENT
a.Building Name/Building Location
Is the facility occupied?
151
MA
d State
b.Building#
Yes ❑No
Asbestos Contractor:
ACCUTECH INSULATION 8 CONTRACTING
a.Name
LUDLOW
c.City/Town
Blanket Decal Number
202 SOUTH STREET
b.Street Address
01060
e.Zip Code
F- I
1056
d.Zip Code
AC000005
f.DOS License Number
b.Facility Contact Person
BRANDON E BESAW
a.Name of On-Site Supervisor/Foreman
N/A
a.Name of Project Monitor
N/A
a.Name of Asbestos Analytical Lab
07/07/2006
a.Project Start Date(mmldtllyyyy)
6:00-4:30
n
(413)584-1506
Telephone Number
1
c.Wmg d Floor
e.Room
100 STATE STREET
b.Address
4135835500
e.Telephone Number
g. Contract Type:
❑Written
❑Verbal
i.Contact Person's Title
I S070407
b
b.Supervisor/Foreman DOS Certification Number
c.Work hours Mon-Fri.
10 a What type of project is this?
❑ Demolition TA Renovation
❑ Repair ❑Other, please specify:
11. a. Check abatement procedures:
❑Glove bag
❑ Enclosure
❑ Cleanup
❑ Full containment
12. Is the job being conducted
anfootap doc•10/02
fl Encapsulation
Disposal only
Ti Other. specify:
b.Project Monitor DOS Certification Number
b.Asbestos Analytical Lab DOS Certification Number
07/07/2006
b.End Date(mmldtllyyyy) ,
IN/A
�d.Work hours Sat-Sun.
b.Describe
b.Describe
J Indoors? E Outdoors?
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Asbestos Notification Form Page 1 of 3 III
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
;100034457
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed,enclosed, or
encapsulated:
52
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
k.Thermal,solid core pipe
insulation
0
b. I otal other surfaces(square it)
Lin.I. Sq.ft.
Lin.ft
Lin.ft. Sq.ft.
Lin.ft. IS ft
52
Sq-ft_
d. Insulating cement
t Trowel/Sprayer coatings
h.Transite board,wall board
Lin.9 Sq.ft.
j.Other,please specify:
I.Specify
Lin.fl.
Lin.ft.
Lin.ft.
Lin ft.
Sq.ft.
Sq.ft.
14. Describe the decontamination system(s) to be used
SEAL CRITICALS WITH 6 MIL POLY,PRE-CLEAN.LAY DROP CLOTH AND REMOVE USING TH
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:
N/A
a.Name of DEP Official
b.tile
c.Date(mridd
14
of Authorization
N/A
e.Name of DOS Official
d.DEP Waiver#
f.DOS Official Title
g.Date(mm/dd/yyyy)of Authorization 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
1 Current or prior use of facility
RESIDENCE
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes ❑ No
3
4
TESSA VAN BUSKIRK
a.Facility Owner Name
NORTHAMPTON
c.City/Town
TESS VAN BUSKIRK
a.Name of Facility Owner's On-Site Manager
_ n I
c.City/Town d Zip Code
01060
d.Zip Code
j
202 SOUTH STREET
b.Address
413-584-1506
e.Telephone Number(area code and extension)
b.On-Site Manager Address
e.Telephone Number(area code and extension)
anfoolap.doc•10/02 Asbestos Notification Form•Page 2 of 3 i
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
Afek
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100034457
Decal Number
B. Facility Description (cont.)
5
N/A
a.Name of General Contractor
c.City/Town
b.Address
d.Zip Code
GRANITE STATE/ZIMMERMAN INSURANCE
f.Contractor's Worker's Comp. Insurer
6. What is the size of this facility?
e Telephone Number(area code and extension)
WC6929778
j.Policy Number
2000
a.Square Feet
11/04/2006
h.Exp.Date(mm/ddrywy)
2
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
01056
d.Zip Code
100 STATE ST. P.O.BOX 376
b.Address
(413)583-5500
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
RED TECHNOLOGIES, LLC 1 i10 NORTHWOOD DRIVE
a Name of Transporter O.Address
BLOOMFIELD 106002 I 1(860)218-2428
c.City/Town d.Zip Code e.Telephone Number
3. 1
4
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
° D. Certification
0
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0
LL
Z
C
44688
f.Zip Code
b.Address
e.Telephone Number
b.Final Disposal Site Location Owner's Name
WAYNESBURG
d C ty/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
t the best of his/her knowledge and belief.
antDOI an doc-10/02
JUDY CROWLEY
a.Name
OFFICE MANAGER
c. Position/Title
(413) 583-5500
e.Telephone Number
11100 STATE ST. P.O.
q.Address
LUDLOW
h.City/Town
LL—
4uth zed Signature
I ([a6/16006 t
Date fmnidd/ywyl
ACCUTECH INSULATIOi
Representing
BOX 376
101056
Zip Code
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Asbestos Notification Form Page 3 of 3