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STRUCTIONS
Commonwealti. Massachusetts
777440
Please Enter Decal#
Asbestos Notification Form ANF-001
Revised #7 1-7-05
Revised #7 1-28-05
All sections of
s farm must be
mpleted in order
comply with
EP notification
auirements of
0 CMR 7.15
d the Division
Occupational
dety(DOS)
'ification
cuirements of
3 CMR 6.12
777440
A. Asbestos Abatement Description
Facility Location:
Go West Building
Name of Facility
Florence
City/Town
Worksite Location:
Basement- 3r4 Floor
1 North Main Street
MA
State
Street Address
01060 N/A
Zip Code Telephone
Building name,#.wing,floor,room
2. Is the facility occupied? ❑ Yes
® No
3. Asbestos Contractor:
AccuTech Insulation & Contracting,
4
5
6
Submit Original
irm to:
rmmonwealth of
assachusetts 7
:bestos Program
Box 120087
tston MA
1112-0087
100 State St., P.O. Box 376
Name
Ludlow, MA
CityiTown
AC000005
DOS License#
Joanne Campbell
01056
Zip Code
Address
(413)583-5500
Telephone
Contract Type: ®Written ❑ Verbal
Facility Contact Person
Dale Hardy
Name of On-Site Supervisor/Foreman
To be determined
Name of Project Monitor
To be determined
Contact person's title
AS71733
DOS Certification#
DOS Certification#
Name of Asbestos Analytical Lab DOS Certification#
n r nc f- 3/.Gf e vA1/45
Project Start Date
7 AM to 4 PM
£z4s20g& ;2f-o.5
End Date
N/A
Work hours Mon-Fri.
8. What type of project is this?
❑ Demolition
❑ Repair
® Renovation
❑ Other, please specify:
9. Check abatement procedures.
Work hours Sat-Sun.
E Glove bag ❑ Encapsulation
❑ Enclosure ❑ Disposal only
❑Cleanup ❑ Other, specify:
Z Full containment
10. Is the job being conducted: Z Indoors? ❑ Outdoors?
FEB ' 1
Asbestos Notification Foci Page 1 of 4
Commonwealtt. Massachusetts
L Asbestos Notification Form ANF-001
L-
777440
Please Enter Decal#
A. Asbestos Abatement Description (cont.)
11. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
515 16,660
pipes or ducts(linear ft) other surfaces(square ft)
Boiler,breaching,duct,tank surface / /
coatings
tin.ft sq.ft Insulating cement tin.ft sq.ft
Corrugated or layered paper pipe 515/ /7,835
y tin.ft s .ft Trowel/Sprayer coatings tin.ft sq.ft
insulation q
/ /
Spray-on fireproofing Itn.ft sq.ft Transite board,wall board lin.ft sq.ft
/ Other,please specify:
Cloths,woven fabrics lin.ft sq.ft
/ 4,375s ft.VAT&Mastic 21s . /
Thermal,solid core pipe insulation lin.ft sq.ft r 9 tin.ft sq.ft
ft ain't nnafinn
12. Describe the decontamination system(s)to be used:
Two layers of 6 mil poly on the walls and floor (where applicable)with an attach. 3 stage decon unit.
Seal critical with 6 mil poly pre-clean, lay drop cloth &remove using neg press glovebag method.
13. 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 company vehicle to
dl inn cite
14. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
N/A
Name of DEP official
Title
Date of Authorization Waiver#
N/A
Name of DOS official
Title
Date of Authorization Waiver#
15. 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
2. Is the facility owner-occupied residential with 4 units or less? ❑ Yes ® No
Valley CDC 30 Market Street
Facility Owner Name Address
Northampton 01060 413-586-5855
City/1-own Zip Code Telephone
Joanne Campbell same as above
4' Name of Facility Owners On-Site Manager Address
.,,.in.auon=9;c2
Retail & Residential
City/Town Zip Code Telephone
Asbestos n 11 JO:
Thage 2 of 4
Commonweat Massachusetts
j Asbestos Notification Form ANF-001
:Transfer
ans must
ply with the
I Waste
,ion
.ilations 310
:19_000
777440
Please Enter Decal#
B. Facility Description (cont.)
Western Builders PO Box 587
Name of General Contractor Address
Granby 01033 413-467-9171
City/Town Zip Code Telephone
WC481-49-86
5.
Granite State Insurance
11/04/04
Contractors Worker's Comp.Insurer Policy# Exp.Date
6. What is the size of this facility?
8,400 3
Square Feet #of floors
C. Asbestos Transportation and Disposal
1.
Transporter of asbestos-containing material from site to temporary storage site Of necessary)to final
disposal site:
AccuTech Insulation & Contracting, Inc. 100 State Street, P.O. Box 376
Name of transporter Address
Ludlow, MA 01056 (413) 583-5500
City/Town Zip Code Telephone
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
Waste Management N.E.E.T., Inc. 25 Silver Street
Name of transporter Address
Portland, CT 06480 (860)342-0667
City/Town Zip Code Telephone
3
N/A
Refuse transfer station and owner
Address
City/Town Zip Code
4. Turnkey Recycling & Environmental Enterprise
Final Disposal Site location name
97 Rochester Neck Road
Address
NH 03839
State Zip Code
Telephone
Turnkey Recycling& Environmental Enterprise
Owner's Name
Gonic
City/Town
(603)330-0217
Telephone
de:Contractor
ist sign this torn
DOS notification
rposes
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.
Nou cation=P/n2
Grace Mitchell
Name
Office Manager
Po sitionftitle
5413) 583-5500
Telephone
Ludlow, MA
City/Town
is g*
uthorized Signeh'e and Date
AccuTech Insula on &
Contracting, Inc.
100 State St, P.O. Box 376
Address
01056
Zip Code
Fee exempt(city,Town,district,municipal housing authority,owner-occupied residential of four units or less?) Yes 0 No
t se.stos nlomf ,n=crn= 3 of 4
,.
Commonwealt Massachusetts
Asbestos Notification Form ANF-001
tam:
filling out
on the
Per,use
e tab key
/e your
- do not
e return
Revised #7 1-7-05
Revised f7 2-2-05
Revised #7 1-28-05 Revised #7 2-24-05
A. Asbestos Abatement Description
777440
Please Enter Decal#
1. Facility Location:
Go West Building 1 North Main Street
Name of Fadlity Street Address
Florence MA 01060 N/A
City/Town State Zip Code Telephone
777440
Worksite Location:
Basement-3rd Floor
Building name,#,wing,floor,room.
2. Is the facility occupied? ❑Yes ® No
3. Asbestos Contractor:
AccuTech Insulation & Contracting, 100 State St., P.O. Box 376
Name Address
RUCTIONS Ludlow, MA 01056 (413) 583-5500
City/Town Zip Code Telephone
sections of AC000005 trm must be Contract Type: ®Written ❑Verbal
feted in order DOS License#
reply with Joanne Campbell
notification Facility Contact Person Contact person's title
rements of
;MR 7.15 Dale Hardy AS71733
he Division 4' Name of On-Site Supervisor/Foreman DOS Certification#
:cupafional To be determined
ty(DOS) 5. Name of Project Monitor DOS Certification#
cafi an n
rements of To be determined
8MR 6.12 6. Name of Asbestos Analytical Lab DOS Certification#
ibmit Original
Ito:
monwealth of
sachusetts 7
=stns Prooram
Sox 120087
on MA
:2-0087
4-14-1-5/2-00-5 ) 'N-C`S_ 2/J//: -24/cj _02A1512096 fW(/dt/a 2-24-05
Project Start Date End Date
7 AM to PM N/A
Work hours Mon-Fri. Work hours Sat-Sun.
8. What type of project is this?
❑ Demolition ® Renovation
❑ Repair ❑ Other, please specify.
9. Check abatement procedures:
1 �3 n, h '� p,1
Z Glove bag ❑ Encapsulation
❑ Enclosure ❑ Disposal only
❑ Cleanup ❑ Other, specify:
® Full containment
ID. is the job being conducted: 7 indoors? ❑ Outdoors?
FEB 2 5 h,�
CA OO;:rE
TP .
Commonweah. Massachusetts
iAsbestos Notification Form ANF-001
777440
Please Enter Decal#
A. Asbestos Abatement Description (cont.)
11. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
515 16,660
pipes or ducts(linear ft) other surfaces(square ft)
Boiler,breaching,duct,tank surface / Insulating cement
coatings lin.ft sq.ft lie ft
Corrugated or layered paper pipe 515/
insulation lin.ft sq.ft Trowel/Sprayer coatings en.ft
Spray-on fireproofing tin ft sq ft
Transite board,wall board
Other,please spec :
Cloths,woven fabrics lin.ft sq.ft
Thermal,solid core pipe insulation tin.ft sq.ft 4,375 sq.ft.VAT&Mastic 21 sq.
ft cink nnafnn
lin.ft
sq ft
/7,835
sq.ft
sq.ft
lin.ft
sq ft
12. Describe the decontamination system(s) to be used:
Two layers of 6 mil poly on the walls and floor (where applicable)with an attach. 3 stage decon unit.
Seal critical with 6 mil poly pre-clean, lay drop cloth & remove using neg press glovebag method.
13. 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 company vehicle to
damn site
14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
N/A
Name of DEP official Title
Date of Authorization Waiver#
N/A
Name of DOS official Title
Date of Authorization Waiver#
15. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? 0 Yes ® No
B. Facility Description
Retail & Residential
1. Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or less? 0 Yes Z No
Valley CDC 30 Market Street
3- Facility Owner Name Address
Northampton 01060 413-586-5855
City/Town Zip Code Telephone
Joanne Campbell same as above
Name of Facility Owner's On-Site Manager Address
City.i own
Zip Code Telephone
1.:e1fl-bT
Transfer
ins must
)Iy with the
I Waste
ion
nations 310
;19.000
Commonweal-. Massachusetts
Asbestos Notification Form ANF-001
777440
Please Enter Decal#
B. Facility Description (cont.)
5.
Western Builders
Name of General Contractor
Granby
City/Town
Granite State Insurance
01033
Zip Code
Contractor's Worker's Comp.Insurer
6. What is the size of this facility?
PO Box 587
Address
413-467-9171
Telephone
WC481-49-86 11/04/04
Policy Exp.Date
8,400 3
Square Feet #of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from
disposal site:
AccuTech Insulation & Contractin9Jnc.
Name of transporter
Ludlow, MA 01056
City/own Zip Code
site to temporary storage site Of necessary)to final
100 State Street, P.O. Box 376
Address
(413) 583-5500
Telephone
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
Waste Management N.E.E.T., Inc.
Name of transporter
Portland, CT 06480
25 Silver Street
City/Town Zip Code
3. N/A
Address
(860) 342-0667
Telephone
Refuse transfer station and owner
Address
City/Town Zip Code
4. Turnkey Recycling & Environmental Enterprise
Final Disposal Site location name
97 Rochester Neck Road
Address
NH 03839
State Zip Code
Telephone
Turnkey Recycling & Environmental Enterprise
Owner's Name
Gonic
City/Town
(603)330-0217
Telephone
e: Contractor
st sign this form
DOS notification
poses
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
8.00 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.
Grace Mitchell
Name
Office Manager
Position/Title
(413) 583-5500
Telephone
Ludlow, MA
City/Town
%QY2'ty
r
h2 `? Pi
/Autt orized Signet 0e and Date
AccuTech Insulation &
Contracting, Inc.
100 State St, P.O. Box 376
Address
01056
Zip Code
Fee exempt(city.Town,district ma.fcioa!housing authority,ownertocotipied residential of four units or less?) ®Yes ❑No