1 Asbestos Notification Form 2005 sa
Commonwealti, Ma_ .achusetts
a ask
777440
Please Enter Decal g
Asbestos Notification Form ANF-001
Revised #7 1-7-05
A. Asbestos Abatement Description
iportant:
hen filling out 1.
nos on the
imputer,use
dy the tab key
move your
asor-do not
ie the realm
ISTRUCTIONS
All sections of
its form must be
mpleted in order
comply with
EP notification
iquirements of
10 CMR 7.15
rid the Division
t Occupational
afety(DOS)
otification
:quirements of
53 CMR 6.12 6.
Facility Location:
Go West Building
Name of Facility
Florence
City/Town
Worksite Location:
Basement - 3rd Floor
MA
State
1 North Main Street
777440 -
Street Address
01060 N/A
Zip Code Telephone
Building name,#,wing,floor,room.
2. Is the facility occupied? ❑ Yes ® No
3. Asbestos Contractor:
4.
5.
Submit Original
orm lo:
:ommonwealth of
lassachuseus 7
s Program
'0 Box'O Box 120087
loslon MA
2:12-0057
NSJhcati00 9/02
AccuTech Insulation &Contracting,
Name
Ludlow, MA
City/Town
AC000005
DOS License#
Joanne Campbell
01056
Zip Code
100 State St., P.O. Box 376
Address
(413)583-5500
Telephone
Contract Type: ®Written
❑Verbal
Facility Contact Person
Dale Hardy
Name of On-Site Supervisor/Foreman
To be determined
Contact person's title
AS71733
DOS Certification#
Name of Project Monitor
To be determined
DOS Certification#
Name of Asbestos Analytical Lab DOS Certification#
07:4542-OOb
Project Start Date
-O2i7-Si?.BBg cl Cl.
End Date
7 AM to PM 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 Sable.,,
15 17b
,
JAN i 0 -2Ui)C
® Glove bag ❑ Encapsulation
❑ Enclosure ❑ Disposal only
❑ Cleanup ❑ Other, specify:
® Full containment
10. Is the job being conducted: ® !ndoors? ❑ Outdoors?
�I HAMPTON WARD or HEADfl
Asbestos tro:if'catior Form
i.
Commonwealtt, MaL echusetts
.. a
777440
Please Enter Decal#
L-
c,: Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.)
11. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
515
pipes or ducts(linear ft)
Boiler,breaching,duct,tank surface
coatings
Corrugated or layered paper pipe
insulation
Spray-on fireproofing
Cloths,woven fabrics
Thermal,solid core pipe insulation
lin.ft sq.ft
515/
lin.ft sq.ft
lin.ft sq.ft
lin.ft sq.ft
/ 4,375 sq.ft.VAT&Mastic 21 sq
tin.ft sq.ft ft cin4 nnntinn
16,660
other surfaces(square ft)
Insulating cement
Trowel/Sprayer coatings
Transite board,wall board
Other,please specify:
lin.ft
lin.ft
En.ft
sq.ft
/7,835
sq.ft
sq.ft
En.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
d,imn 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
I. Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes ® No
Retail & Residential
3.
Valley CDC 30 Market Street
Facility Owner Name Address
Northampton 01060 413-586-5855
City/Town Zip Code Telephone
Joanne Campbell same as above
4. Name of Fadlity Owners On-Site Manager Address
City/Town
Notification 9/02
Zip Code Telephone
Asbestos Notification Form•Page 2 of 4
te:Transfer
rtions must
nply with the
lid Waste
Asian
gulations 310
AR 19.000
r► r►
Commonwealfi. Ma_,.achusetts
Asbestos Notification Form ANF-001
777440
Please Enter Decal
B. Facility Description (cont.)
5.
Western Builders PO Box 587
Name of General Contractor Address
Granby
City/Town
Granite State Insurance
01033
Zip Code
Contractor's Worker's Camp.Insurer
6. What is the size of this facility?
413-467-9171
Telephone
W C481-49-86
Policy#
8400
Square Feet
11/04/04
Exp.Date
3
#of floors
C. Asbestos Transportation and Disposal
1.
Transporter of asbestos-containing material from site to temporary storage site (if necessary) to final
disposal site:
AccuTech Insulation & Contractinq, 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
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
te
City/Town Zip Code Telephone
4. Turnkey Recycling & Environmental Enterprise Turnkey Recycling & Environmental Enterprise
Final Disposal Site location name Owner's Name
97 Rochester Neck Road Gonic
Address City/Town
ote:Contractor
rust sign this form
it DOS notficalion
urposes
Notification• 9/02
NH
State
03839
Zip Code
(603)330-0217
Telephone
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.
Grace Mitchell
Name
Office Manager
Position/Title
(413)583-5500
Telephone
Ludlow, MA
City/Town
orized Signat e and Date
AccuTech Insula ion &
Contractinq, 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?)
0 Yes ❑No
Asbestos Notification Form• Page 3 of 4