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421 N Main St. Asbestos Abatement 3-27-20 #100326269AElvolollmmei PO BOX 929 1VOI2'iI3 BORo, MA 01532 greg@aerotecasbestosreineval.com PHONE. 978-375-9534 FAX: 508-393-3365 ATT : BOH Fax : 413-587-1221 FROM: Greg Harding DATE: 3/26/2020 PAGES: l'd ZL9866L909 ft!1O'OZ9ZanW Massachusetts Department of Environmental Protection -- BWF AQ 04 (ANF -001) 100326269 Asbestos Notification Form Asbestos Project # i Project Revision -' r- Project Cancellation A. Asbestos Abatement Description 11. 1, Facility Location: NORTHAMPTON VAMC_ 421 N MAIN S7 Instructions 1. All _ _ a. Name of Facility - b, Street Address sections of this four NORM-ANIF70N must be completed in MA 01053 413.5844040 order to with c, CitylTown d. State e. Zip f. Code Telephone MassDEp notifinotHi cation JOSE GOLDIN requirements of 310 COTAR CMR 7.15 and g. Facillty contact Person Name h. FWllty ConLzct Person Title R Deparhmni of Labor WOrkgl[e Location: Standards (DLS) B-20 notification ii. Building Name, Wing, Floor, Roam, etc.—-.- ­ requirements of 453 2, Is fhe facility occupied? 1`a. Yes CMR 6,12 ;F%b. No 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)? r- a. Yes )w b. No MasSCYcP Use Only 4. Blanket Permit Project .Approval, if applicable: Date Received Approval 10 # 5, Non -Traditional Asbestos Abatement Work Practice Approval, ifapplicable: 6. Asbestos Contractor: AERO TECH ENVIRONMENTAL 163 RICE AVE a. Name Is. Address NOFTHBOROUGH MA 01592 9783759534 c. Cily7rown tl. Btate e. Zip Code fT Tcuphune — AC000921 _ -- h. Contract Type: iv 1. Written r— 2. Verbal g KS Licenses# ANDERSON MARTINEZ AS902444 a. Name of Connaaors On -Site Supervisor/Foreman i. DLS Certification ik 8. KEVIN DONOVAN AM001856 a. Name of ProjeC. MonitorCeni7caGon e 9 MABBETT R ASSOCIATES, INC. AA000234 e. Name of Asbestos Analytical Lab b. OLS Cedif,",on # ��- 10. 3/2712020 3/3'1/2020 a. Project Siert Data (MM1DDWYY) b. End Date 7A,M WM 7AM SPM d. Work Hours- Monday Through Friday d Work Hours - Saturdey & Sunda;---- unday- 11. What type of project is this? fw it. Demolition j-" b. Renovation r' C. Repair r- d. Other • Please Specify: Reviscd: 11/13/1013 -'- — ----- Page 1 o(-4 Z'd Z1996BL909 d9ZI10'0Z,9Z oatj Massachusetts Department of Environmental Protection L--'- B�'�° ACS dBW ( —OQ1� IGos2569 Asbestos Notification Folin Asbestos Project r- Project Revision - - f Project Cancellation A. Asbestos Abatement Description: (cont.) 12. Abatement procedures (check all that apply): r' a. Glove Bag r- b. Encapsulation i- c. Enclosure r- d. Disposal Only I" e. Cleanup W f. Full Containment T- g. Other - Please Specify: 13. Sob is being conducted: I- a. Indoors 'W b. Outdoors 14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or encapsulated: so 1 linear Feel (Lin. Ft.) 2 Square Feat (Sq. r -t.) b. Boiler, Breaching, Duct, Tank Surface Coatings d. Pipe Insulation f. Spray -On Fireproofing h. Cloths, Woven Fabrics i. Insulating Cement 1. Lin. Ft. 2. Sq. Ft 1. Lin. Ft. 2. Sq. Ft b. Title of MasaDER Official iw 1. Lin. Ft. 2. Sq. FFL t. Linin. Ft. 2. Sq, Ft. 1. Lin. Ft. 2. Sq. Ft 15. Describe the decontamination system(s) to be used: 3 CHAMBER WASH BUKET C. Transite Pipe e. Transite Shingles L. Transite Panels i. Other - Please Specify: 50 1. Lin. FL 2. Sq. Ft. L Lin. Ft. 2. Sq, Ft. L Lin. Ft. 2. Sq. Ft, 15. Describe the containerizatioxl/disposal methods to comply with 310 CMR 7.15 and 433 CMR 5.14(2) (d): 5 Mill DOUBLE BAG 17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency: _ DAVID SLOWICK P1sPectOR p. Name of MassDEF Official b. Title of MasaDER Official iw 328/2020 W -AW -20-193 c. Dates. Date of Authorization (MMIDD/YYVY) d. WpiverN BOSTON ­D BOSTON e. Named LS ---" f. Titlo o DDLS Official wee/2020 286606-2020 9.Oale of Authorization(MMAXJMYY) h.Waivet 18. Do prevailing wage rates as per M.G.L. c. 144, § 26, 27 or 27A -F apply to this 17 a. `des ri b, No project? Revised: 11/13/`2013 — a e7of4 6'd 7,L9856L809 d9L:L0'069ZaeW Massachusetts Department of EnvironmentaI Protection ---- \`\ BWP AQ 04 (ANF -001) !100326269 Asbestos Notification Form Asbestos Project tl r Project Revision "'--"`- ^w• r Projecteancella.tion B. Facility Description I. Current or prior use of facility: HO SPMAL 2. Is the facility Owner -occupied residential with 4 units or less? f- a. Yes r b. Nn q NORTHAMPTON VAMC 421 N MAIN ST a. Facility Owner Name ��-�-��—'— b. Address --" NORnit✓KON _ MA 01053 4130844040 C. City7Towri d. State e, Zip Code f. TetOphone '�' 4.NA NA a. Name of Facility Owners Or—Sl Manager b. Address NA ___,,, MA 00000 00600 CO _ c. CitylTown d. State e. Zip Code f. TeIP-phone -- 5.---AERO TEC ENVIROWENTAL 163 RICE AVE N _a_ a. me of —General Cantraotor "` =....,.. N0;7HBCRClJGH MA 01532 9783759534 c. Cityfrown d. State a. Zip Codn t. T'elephana ACE. g. Gbntraclol"s W6rker'6 Oompensation Insurer -- --- 656206 .— 5/7/2021 h. Pdiay k i. Exwitlon nate (Mrvi Do j b. What is the size of this facility? 30000 2 a. Square Feol b_# -of Floors Nate: Temporary storanc rf Asbestos C.AsbestosTransportation & Disposal cents nine waste 1 material Is only T'ransnorter of asbestos -containing waste material from site of generation: allowed at the place j - a.. Directly to Landfill or w b. To Temporary Storage Location/Transfer Station of business of a 01-5 I conned Asbestos contractor or a transfer AERO TEC ENVIRONMENTAL permitted by 163 RICE AVE stamen that y c. Name of Transporter "-` _`�-_— ptl. Address --"" "— MassOEP and NORTHBOROUGH MA 01532 9783759534 operated in e, CifylTown compliance with Solid I. State g. Zip Ccdo — h. Telephone Waste Regulations 310 CMR 15.000 ?. If a temporary storage location./transfer station is used, list name of transporter of asbestos containing waste material from temporary storage t0catiom'transfer station to final disposal site: RTI 173PICKERINGST a. Noma of Transporter-- b.Address PCRTLMD Gr 06480 8603422923 as C>hrlTawn _ d. State e. Zip Code 1. Tefephdne---__-- Revised 11,,13/2013 --~Page s Of t. d ZL9966L909 d97Zf) oZ 9Z mVJ Massackisetts Department of Enviromnental Protection------- BWP AQ 04 (ANF -001.) 100326265 _y Asbestos Notification Form Asbestos Project # r Project Revision L7 -1 r Project Cancellation C. Asbestos Transportation & Disposal: (cont) 3, Name and address of temporary storage location/transfer station for the asbestos containing waste material: Note: Contractor must sign this form for OLS notification purposes Sd NA _ NA a.1'emporary Storage Location me Nab, Address ���� NA MA 00000 0000000000 C, C:Ity?awn d. State a. Zip Code i. Telephone 4. Name and location of final disposal site (asbestos landfill): MINEWAENTER"IP4E MINERVA ENT a, Final Disposal Site Name __ b. Final Disposal S!e Owner Name 90)0 MIMINGRVA RD c. Address MINERVA __ OH 44666 3306663535 d. City o -own �� e. State 1. Zi Code _ --- p ' g.Telephone D. Certification "I certify that I have personally examined the foregoing and am familiar with the information contained In this document and all attachments and that, based an my inquiry of those Individuals immediately responsible for obtaining the information, I believe that the information Is true, accurate, and complete. I am aware that there are significant penalties for submitting raise 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 Standards and 310 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 app;icable fee is rnade." 1/1 ZL9966/909 GREG HARDING 1. Name OWNER 3. FosibonRtie 9763759534 5. Tele�7;0-- -�� 163 RICE AVE 7. Addross MA 9. State GREG HARDING 2. Authorized Signature 3)26!2020 A. Date (MMIDDMIYY) ___-- AERO TEC 6. Representing NORTHBORouGH a. clty/Tovm — 01532 10. Zip Code Pace 4 of 4 d97'LO'oZ 97.IeA Massachusetts Department of Environmental Protection .-B vy P AQ 04 (A;NF-001) lUQ3"l5)Q5 Asbestos Notification Fornl Asbestos ProjectIL T- ## Project Revision r- Project Cancellation A. Asbestos Abatement Description 10. 3/27,"2020 a. PraVot Sart Date (MM/DDNYYY) '- 5AM 9PM c. WorkHaurs - Monday Through Friday 11. What type of project is this'.! 3/30/2.020 b. End Date (MMODIWyy) —— 5AM 9PM tl, LVliaya Sunda oul - Saturtly ` r" a. Damoiition IW b. Renovation r- c. Repair t-" d. Other - Please Specify: Page I of 4 9'd ZZ9966Z309 dSZI10'0Z 9Z 1o4"d 1. Facility Location: NORTI-W IPTON VAMC 421 N MAIN ST Instructions 1. All a. Name of sections of Ibis form b. Straet Address "--""-' must be completed h. NCRtFlWl4FrfCA�l_ MA 01053 4135844040 order to comply with MassDEP notification d. State a. Zip Code F. Telephone c, CiEE requirements of 310 'SEE GOn LDIN CCTAR CMR 7.15 and 9. Facility Contact Person Name---��---' a� b. FacilRy Contact Person Title Department of Lebo, Worksite Location: Standards (OLS) B-20 notification t. eUild NalName, Wing, Floor, Room, requirements of 453 2, IS the facility Occupied? 1" R. Yes TV b. No CMR6.12 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or tu9assDEP Use Only owner -occupied residential property Of four units or less)? I- a. Yes Tv` b. No 4. Blanket Pennit Project Approval, if applicable: Date Received Approval ID it '-""-`- S. Non-traditional Asbestos Abatement Work Practice Approval, if applicable: Approval ID 6. Asbestos Contractor: AERO TECH ENVIRONMENTAL 163 RICE AVE a. Name b. Address NOR'1}ISOROUGM MA 01532 9783759534 a City?own-�"— d. State e. Zip Code f. 7elephmo _ -'- A0000921 h. Contract Type: Tv 1. Written 2. b'erbal qD . LS Lkense # '- 7. ANDERSON MARTINEZ_ AS902444 a. Name or Contractofs On -Site S.�9lvlscrlForeman b, DLS Certiticetmn# `— 8 KEVIN DONOVAN AM001856 a. Name of Project Mpnjtor `—'- b. DLS Certification N 9. MAeSETr&ASSOCIATES, INC. AA000234 a. Name of Asbestos Anelylical Lab---��'--�- FEE Certification # -'- 10. 3/27,"2020 a. PraVot Sart Date (MM/DDNYYY) '- 5AM 9PM c. WorkHaurs - Monday Through Friday 11. What type of project is this'.! 3/30/2.020 b. End Date (MMODIWyy) —— 5AM 9PM tl, LVliaya Sunda oul - Saturtly ` r" a. Damoiition IW b. Renovation r- c. Repair t-" d. Other - Please Specify: Page I of 4 9'd ZZ9966Z309 dSZI10'0Z 9Z 1o4"d Massachusetts Department of Environmental Protection BWP AQ 04 (ANF_001) 100325905 Asbestos Projcot # Asbestos Notification Porn, I- Project Revision Ei r Project Cancellation A. Asbestos Abatement Description: (cont.) 12. Abatement procedures (check all that apply): )'"i• a. Glove flag 7 b. Encapsulation yv c. Enclosure ;r d, Disposal Only ) e. Cleanup dv f. Full Containment f— g. Other -'Please Specify: I3. Job is being conducted: W a. Indoor: i U. Outdoors 14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or encapsulated: 30 7. Linesr Fee[ (Lin. Fi.) -� 2. Squafe Feet (Sq. Ft.) b. 13oilcr, Srcacbhtg, Duct, C. Transite Pipe Tank Surface Coatings T. Un. FF 2, Sq. F't. d. Pipe Insulation _ c. Transite Shingles 7. Lin Ft. 2, sq.Ft. f. Spray -On Fireproofing L Lh Ft. Z. Sq, Ft. h. Cloths, Woven Fabrics 30 T Lin. Ft7 2. Sq.t. J. insulating Cement 1. Lin, Ft. E. Sq. Ft. 15. Describe the decontamination system(s) to he used: 3 CHAMBER WASH BUCKET g. Transite Panels i, Other - Please Specify: FT,, MA, ROPE GASKET 1. Lin, R 2, Sq. Ft. L Lln, Ft. 2. Sq. Ft. T. linin. Ft. 2. Sq. Ft. 236 •I. Lin. Ft 2. Sq. Ft. 16. Describe the conta:nerization/disposal methods to comply viltb 310 CMR. 7.15 and 453 CMR 6.14(2) (g): 6 MLL DOUBLE BAG 17. For. Emergency Asbestos Operations, the, MassDRP and DLS officials who evaluated the emergency: a. IJa,me of -Ma ssDEP Official _.__ b. Title of MassDEPCNficial c. Dale ofAiRhorizatlon (MR4/DD/Yl'1"/) d. Waiver e. Name of DL5 OtP'icial Fl of DLS Oficial p. Dake of Authprir_ation (MM/DDlYY1'1') h. Waiver# 18. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A -F apply to this a• Yes f- b. No project'? ,J L'd ZL9866L90S Paee 2 of 4 d6Z:Z0 V 9Z JIM Massachusetts Department Of Environmental Protection BWP Aid 04 (ANF" -001) Asbestos Notification Form B. H!acbdjty Description 1. Current or prior use of facility: HOSPITAL 100325905 Asbestos Project N I"• Project Revision F' Project Cancellation 2. Is the facility owner -occupied residential with 4 units or less7 I– a. Yes is b. No 3 NOR-fHAMPTON VAMC MA 01532 421 N MAIN ST C' CdyITown a. Facility Owner Name _ ACE: NORTWIMPTON MA 01053 4135644040 a Cityi fown d. State a. Zip Code f. Telephone 4. NA 5/7/2021 NA _ a. Name of F8cillty Uynees On -Site Manager G. What is the size of this facility? b. Address 2 RA MA 00000 0000000000 c. Cay/Townd. State e. 2F('Ode f. Telephone 5. ARC TEC 163 RICE AVE 3.—N ame of General Contractor p. Address " NORTHBORO MA 01532 9783759534 C' CdyITown d_slate e. Zip Coda f 7,1Eaphnrle ACE: g. COOtraet WolWod(ees Compensation Insurer ------ 656208 h, Pu6oy k 5/7/2021 1. Expiration Date (MODD/Y- ) G. What is the size of this facility? 36000 2 a. square Feet ____ b. # of Floors '- Note: Temporary C Asbestos Transportation sof Asbestos ngjltArtat8.C3I1 4%L D(gDisposalDisposalcanl4i n:ntaining waste male^iel is only I- Tral'1spOrteT of asbestos -containing waste material from site of generation: allowed at the plata �"" a. Directly to Landfill or P b. To Temporary Storage Location/Trrinsfer Station o; business of a DLS licensed Asbestos contractor or a transfer AEROTECENIVIRCxNMENTAL 163 RICE AVE nernnined y a Name of Transporter permifled by tl. NassDEP and NOf7THBOR0 _ MA 01632 97837595$4 operated In a, Cityfrovm f. Stitd rompeanco with Solid 9• Zip Code h. Telephone -- Wamo Regulations 310 CMR 19.000 2, If a temporary storage location/Vansfer station is used, list name of transporter of asbestos containing waste material from temporary storage location transfer station to foal disposal site: RTL __ 173 PICKERNG ST a. Name of Transporter �'� b. Address PORTLAND _ Cr 06480 8607202923 c. Citylfown d. State e. Zip Cada t Telephone Revised: 11/5/2013 – – – Pane 3 of 4 9'd ZL9eruRos d091LO'079L'eVJ Note: Contractor must sign this fo•m for OLS no;ifica6on purposes Massachusetts Department of Environmental Protection BW AQ 04 (ANS' -001) 1 P 1100325905 Asbestos Notification Form Asbestos Projecttl r' Project Revision f Project Cancellation C. Asbestos Transportation &. Disposal: (cont.) M -- 3. Name and address of temporary storage location/transfer s material: ration for the asbestos containing waste NA NA a. Temporary Storage Location Nam,--- b. Address NA _ MA 00000 0000000000 a City/1'own d. Stele o. Zip Code f. Telephone 4. Name and location of final disposal site (asbestos landfill): MIARVA ENTERPfWE _ MNERVA iw a, rinal Disposal S NName " b. Final Disposal Slte Owner Namo-_---^�- 9000 MINERVA RD c. Address WAYNES%RG CH 44888 3308663435 d. City(fown a. State f. Zjp Code g. TelephoFe A Certification 1 certify ;hat I have personally examined the foregoing and am familiar with the information contained in this document and Oil attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the information is true, accurate, and Complete. I am aware that there are significant penalties for submitting false information. including possible fines and imprls.onment. The undersigned hereby states that I have read the Commcnweallh of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 Promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shaft riot be deemed Valid unless payment of the applicable fee is made. - GREG HARDIN 1. Name '— aAtER 3. PositJORMIe 9783759534 5. Telephone 163 RICEAVE T Address MA 9. State GREG RARD1NG 2. Authorized Signature 3/17/2020 4. Date Fmr, DIY YY) AEROTEC 6, P.eprp-senting-��-��- NICRT7-18Oi000N aCitylrwn 01532 10. Zip Code Revised: 11/13/2013 ----�- --_ _ Page 4 of 4 6'd ZL9966L80S di,c:/o OZgZjeW