421 Asbestos Notification 2/10/20 Massachusetts Department of Environmental Protection 100323712
BWP AQ 04 (ANF-001) Asbestos Project#
Asbestos Notification]Portals r— Project Revision
r Project Cancellation
A.Asbestos Abatement Description
1.Facility Location:
NORTHAMPTON VAMC 421 N MAN ST
Instruction5 1,All a.Name of Facility b.Street Address
sections of this form NORTHAMPTON MA 01053 41136844040
must be completed In
order to comply with c.City/Town d.Stale a,Zip Code f.Telephone
MessDEP notification JOSEE GOLDIN COTAR
requirements of 310
CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title
Department of Labor Worksite Location: BUILDING 20
Standards(OLS) 1.Building Nane.Wing,Flo I or,Room,etc.
notification
requirements of 453 Z Is the facility occupied? 7—a.Yes Wb.No
CMR 6.12
- 3. Is this a fee exempt notification (city,town,district,municipal housing authority,state facility, or
owner-occupied residential property of four units or less)? I— a.Yes W b.No
MassDEP Use Only
4.Blanket Permit Project Approval,if applicable;
Date Received Approval 10 1
5.Non-Traditional Asbestos Abatement Work Practice Approval,
if applicable: Approval JDO
6.Asbestos Contractor;
AERO TECH ENVIRONMENTAL 163 RICE AVE
a.Name b.Address
NORTHBOROLIGH MA 01632 9783759534
c.City/Town d.State e.Zip Code - f.Telephone
A0000921 h.Contract Type: F 1.Written 1—2.Verbal
g.DCS License N
7. ANDERSON MARTINI-7 A5902444
a.Name of Contractor's On-Sle Supervisor/Foreman b,DILS Certification#
KEVIN DONOVAN AW01856
a.Name of Project Monitor b.OLS Certification#
9. MABBETT&ASSOCIATES,INC. AA000234
a.Name of Asbestos Analytical Lab b.OLS Certification#
to.
2110/2020 PJ 10/2020
a,Project Start Date(NIMIDD/YYYY) b.End Date(MM/DDrYM)
7AM SPM 7AM5PM
c.Work Hours-Monday Through Friday d.'Mork Hours-Saturday&Sunday
11.What type of project is this?
r a.Demolition 1; b.Renovation r c.Repair r— d.Other-Please Spccify:
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r
Massachusetts Department of Environmental Protection 1� 00323112
BWP`AQ 04 (AIF'-001)
Asbestos Notification Form Asbestos Pro I—
t#
f"` Project Revision
` 'r- Project Cancellation
A.Asbestos Abatement Description:(cont.)
12.Abatement procedures(check all that apply):
W a.Glove Bag T- b.Encapsulation r c.Enclosure;r d.Disposal Only f--e.Cleanup
F f.Full Containment r" g.Other-Please Specify:
13.Job is being conducted: l7w, a.Indoors r' b. Outdoors
14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:
100
1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.)
b.Boiler,Breaching,Duct, c,Transite Pipe
Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft
d.Pipe Insulation too e.Transite Shingles
1.Un,FL 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft
f.Spray-On Fireproofing g.Transite Panels
1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
h.Cloths,Woven Fabrics i.Other-Please Specify:
1.Lin.FL 2.Sq.Ft.
j.Insulating Cement
1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft.
15.Describe the decontamination system(s)to be used:
3 CHAMBER WASH BUCKET REMOTE
16.Describe the containerization/disposal methods to comply with 310 CMR'7.15 and 453 CMR 6.14(2)
(g):
6 MILL DOUBLE BAG
17.For Emergency-Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency:
MAY LAPLANTE DEP OFFICAIAL
a.Name of MassDEP Official ti.T'Rte of MassDEP Official
2/612020 W-AW-20-76
c.Date of Authorization(MMlDDIYYYY) d.Waiver;#
BOSTON BOSTON
a.Name of DLS Official L Title of DLS Official
2!712020. 20217.2020
g.Date of Authorization(MM/DDIYYYY) h.Waiver#
S.Do prevailing wage rates as per M.G.L.c, 149,§26,27 or 27A—F apply to this
We a.Yes r b.No
project?
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Massachusetts Department of Environmental Protection 11323712
'BWP AQ 04 (ANF-001) Asbestos Project#
Asbestos Notification Fonaat �
�"` Project-Revision
I- Project Cancellation
B.Fa.eility Description
1.Current or prior use of facility: HOSPITAL
2.Is the facility owncr-occupi.cd residential with 4 units or less? ,T— a.Yes P b.No
3 NORTHAMPTON VAMC 421 N MAIN ST
a.Facility Owner,Name b,Address
NCRTHAMPTON MA 09053 4136844040
c.CityfTown d.State e.by Code L Telephone
4.NA NA
a.Name of Facility Owner's On-Sae Manager b,Address
NA MA 00000 0000D000D0
c.City/Town d.State e.Zip Code f,Telephone .
AERO TEC 163 RICE AVE
S'a.Name of General Contractor b..Address
MRTHBORO MA 01532 9783759534
c.CiylTown d,State e.Zip Code f.Telephone
ACE
g.Contractor's Worker's Compensation Insurer
656208 517/2020
h.Policy# I.Expiration Date(MMIDD.IYM)
6.What is the size of this facility? 21000 3
a.Square Feet b.#of Floors
Note:Temporary
storage of Asbestos Asbestos Transportation &Dir' oral
conlamaterial
is waste I.Transporter of,asbestos-containing waste material from site of generation:
material is only -
allowed at the place i'" a.Directly to Landfill or W+ b.To Temporary Storage Location/Transfer Station
of bwlness of a OLS
licensed Asbestos
contractor or a transfer AERO TEC EW RONMENTAL 183 RICE AVE
station that is a Name of Transporter d.Address
permitted by
MassDEP and NORTHBORO IVA 01532 5783759534
operated in
compliance with Solid a.City/Town f.State .g.Zip Code h.Telephone
Waste Regulations
310 CMR 59.000 2,If a temporary storage location/transfer station is used,list name of transporler'of asbestos containing
waste material frorn temporary storage location/transfer station to final disposal site:
RTL 173 PICIKERING ST
a.Name a:Transporter b.Address
PORTLAND Cr 08480 8807292923
c.City/Town A.State e.Zfp Code f.Teleptt'one
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4 Massachusetts.Department of Environmental Protection �100323712
.P ,
-- BWAQ 04 (.SNF-001 I
Asbestos Project#
Asbestos Notification Forza 1"` Project Revision
r Project Cancellation
C.Asbestos Transportation&)disposal: (cont.)
3.Name and address of temporary storage location/transfer station for the asbestos containing waste
material:'
NA NA
a.Temporary Storage Location!"lame � b.Address
NA MA 00000 0000000400
c.CtWown d.State e,Zip Code f,Telephone
4.Name and location of final disposal site(asbestos landfill):
UNMVAe4TEVRCr= MINIERVA INV
a.Final-Disposal Site Name b.Final Disposal She Owner Name
9 DONNERVARD
c.Address
WAYNESBERG OH 44668 3308663435
d.City/Town. e.State f.Zip Code g.Telephone
Notre:Contractor must
sign this form for DLS
notification purposes D. Certification
GREG HARDING GREG HARDING
"I certify that I have personally 1.Nacre 2.Authorized Signature
examined the foregoing and am OWNER 2/712024
familiar with the information 3.Posltlonrrifie 4.Date tMMtDDlYYYY}
contained in this.document and
all attachments and that,based 9783759534 AEROTEC
on my inquiry of those 5.Telephone 6.Representing
individuals immediately 163 RICE AVE NORTHBOROUGH
responsible for obtaining the 7.Address 8.Citylrown
information,I believe that the MA 41532
Information is true,accurate,and g,grate 10.Zip Code
complete.I am aware that there
are significant penalties for
submitting false information,
including possible fines and
imprisonment.The undersigned
hereby states that I have read the
Commonwealth of
Massachusetts regulations
governing asbestos abatement
(453 CMR 6.00 promulgated by
the Department of Labor r
Standards and 340 CMR 7.15
promulgated by the Department
of Environmental Protection),
and that I am aware that this
permit application or notification
shall not be deemed valid
unless payment of the
applicable fee is made."
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