421 N Main St. Asbestos Abatement 6-11-20 #100328368Massachusetts Department of Environmental Protection 1'"---- --- —
100i�283fits'
BW AQ 04 (ANF -101) I- �. _.. ._._
Asb stos Project k
Asbestos Notification Farm �rp;ecl. Revision
��_.__ f'" I}rgject Cancellatic
Instructions I. All
sections of this form
must be comnleled In
oreer to comply with
MarisDEP notificaticn
rec ulremenls of 310
CMR 7.15 and
Deeartment o' Labor
Siondards (OLS)
notiicat:on
reguiram�nls cf 453
CMR6.12
M3ssD11P Use Only
Da!o Recow;d
A., Asbestos Abatement Description
1. Facility T,ocation:
NORTHAh1P''ON VAMC
a. Name of Facility v
NORTNANPTON
421 N MAIN ST'
b. Street Address
MA 01053 4/35644040
d. stato e. Zip Code f. Telephone
JQiEEGOLDIN C.O1p,R
g Facility Contact Few i Name~ h, Facility contact Person Title
Worksite Location: Mi R102150,1260,252
i, Building Name, Wina, Floor, Ron
2. Is the facility occupied? W n. Ycs Y -b. No
3, Is this a fee exelrpt notification (city, town, district, municipal housing authorlstate facillty, or
owner -occupied residential property of four units or less)? r– a. Yes IN b. 1, f�
4. Blanket Permit Projoot Approval, Vapplicable:
S. Non-Traditioual Asbestos Abatement Work Practice Approval,
if applicable: Approvanb
6. Asbestos Contractor:
AEROTECH ENVIRONMENTAL
a. Name
NORTHBOROUGH
c. City?own
AC000921
g. DLS License #
163 ME AVE
b, Address
MA 01532 033759534
d. SPate e. Zip —Coda—
It,
odeIt, Contract Type: Com' 1, Written
7
ANDERSON MARTINEZ_
AS902444
a. Name of Contractors On -Site_ Supeivisor/Foreman
b.—Dl. S Cerdficatic
8.
EDWARD
"—_�--r. KQLQGZIEJ
AM001303
__..,
a. Name of Pneiect Monitor
6, DLG Certificatk
9.
ATC GROUP SERVICES IW AA000005
--'
-
a. Name of Asbestos Anallrtical t.ab --
b. QLS t:erCrticatic
10.
6/11/2020
6/15/2020
a. Project Star, Date (MMlDDrYYYY)
b. End Date (I,dM11
6;30Ary -8:00 PM
6:30.8:OOP
c. Work Hoare -Monday 7httx:gh Friday
d. Work Hours -
rY
l1. What type of project is this?
f- a. Demolition lv b. Renovation r– c. Repair r` d. Other- Please Specify:
Revised: 1
9"d 99£££6£909
2. Verbal
Page 1 of 4
0e-0i,ay WdCt:IQ70Y,90unr
yMy�s/aas/�aYcihusetts Department of
of Ep®nq{vironmental. Protection.
AQ 04
s�
Asbestos Notification Form
A. Asbestos Abatement Description: (coat.)
10(-128368
Ast estos Project rF
r- reject Revision
F- Irojectcancellation
12. Abatenteut procedures (check all that apply):
I- a. Glove Bag y— b, Encapsulatiotl r — Enclosure I— d. Disposal Only r e.
W E Full Contanunent r" g. Other Please Specify:
13. Job is being conducted: Fr a, Tndoors I"' b, Outdoors __...
14 a. Total amount of each type of asbestos Containing materials (ACM) to be
encapsulated:
rig
1. Linear Feet (Lin. Ft.) � a..._._� 2, Square Feet (Sq. FQ
b. Boiler, Breaching, Duct, c. , ransire Pipe
Tank Surface Coatings .. Lm. F't. z. Sq. Ft. .—
d. Pipe ]Insulation e. Transite Shingles
f. Spray -On Fireproofing
h. Cloths, Woven Fabrics
j. Insulating Cement
1. Lin. Ft. 2. Sq. Ft.
1. Lin, Ft. V. 2.50. Ft.
1.5r-, -F!— 2. 8q. Ft.
15. Describe the decontamination :ystem(O to be used:
3 CHAMBER WASH BUCKET
enclosed, or
i. in. FL 2. Sy,
g. Transite Panels
?. in. Ft. 2. Sq,
i. Other - Please Speer:
Fr, MAnc
_ 506 _
1. ; n. Ft. 2, Sy, Ft.
15. Describe the containerization disposal methods to eotaply with 316 CMR 7.15 and
(g)'
61MLL DOUBLE BAG/MARRELS
17. For Emergency Asbestos Operations, the MassDEP and DLS officials who
a. Name of MasSDEF Official
a Date ofAulhorizatlon (MMJDDA'Y)'Y)
e. Nome of DLS Official
J. Data ofAutnonzation (MM/DDIYYYY)
;3 CIVIR 6.14(2)
the emergency:
18. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A -F apply to this �� I. Yes r++ b. No
project?
Aevisea: 11i 15/ZU13 Pane J_ o: 4
/_'d 99£££6£909 oc-,)_oaeV uadt, t: L oZ,OZ SO ttrf
Note: Temporary
storage, of Asbestes
containing waste
material is only
allowed at the place
of business of a DLS
licensed Ashestos
contractor or a transfer
station drat Is
permitted by
MassOEP and
operated in
compliance with Solid
waste Regulations
310 CMR 19.000
Ma3sachusetts Department of bnvirormentat Protection
BWP AQ 04 ('ANF -001) !10 328368
#
Asbestos Notification Form 'TS-1estos Project
(` roject Revisio^.
I` reject Cancellation
B. Facility (Description
1. Current or prior use of facility:
HOSPITAL
2. Is the facility owner -occupied residential with 4 units or less? r` a. Yes PV b. No
1 NORTHAMPTONWIX
421 NMAIN ST
o, facility Ow;rer Name
b. Address
NORTPAMM14
MA 01053 4135844040
o. City,?own
d. State, e. Zip Cade I. Telephone
NA_—_.�......_...._._��_—� NA
-a. Name of Fact ty Owner's On -Site Manager
NA _ MA 00090 0000000000
a Cttyf1'nvm
-id-Slate e. Zp Oode f. Telophonc
5 . PERO TEC 163 RICE AVE
a. Nsrne of General Contractor h nn� c—
NoFm-fB0RCUGH MA 01532 57,63759534
c. City%wn d, Stale a. Zip Code f. Telephone
ACE
656208 5/712121
I- Policy --R -- I, Eplrat
6. What is the size of this facility? 2
a. Sgiare Feet b
C. Asbestos Transportation & Disposal
1. 'fransparter of asbes:Os-containing waste material from site of generation:
V, a. Directly to Landfill or W b. To Temporary Storage Locatio111Transfer
AERO TEC EWIRONMENTAL 163 RICE AVE
a Name of Tranapolter d. adArc.cc
NORTH60ROUGH MA 01532 9763759534
e. Cityrbwn e f. State g. Zip Code� h. Telephone
2. If a temporary storage locatio Vhansfer station is used, list name of transporter of a4stos containing
waste materia; from temporary storage locationhransfer station to final disposal site: I
RTL 173 PICIERING ST
a. Name of TransporterM b. Address
PORTLAND Cf owe 6603421324
o. CitviTawn dd. Stat- 0. ZIP Code T Telephone
Revised: 11/1
Page 3 of
£1'd 49£££6£805 oay aey utd4l i l OZ07 90 w11•
Massachusetts Departrnent of Environmental Protection
_-_ 93WP AQ 04 (ANF -001) 100328368
�+ As estos Project #
Asbestos Notification Form i ProjectRevision
roject Calicchatior
C. Asbestos Transportation Rc Disposal: (cont.)
3. Name and address of temporary storage location/transfer station for the asbestos con tainin.- waste
material:
NA NA
E, Temporary Storage I_ocakin Flame b. Address n
NA _ MA 00000 0000000000
c C417 vn d. Slate e. Zp Code f. Telephone
4. Name and location of final disposal site (asbestos landfill):
MINERVAQ`I"5 P4 ICENV
_____ MINERVAI
a. F ret Disposal Site Name b, Final Disposal Site Owner Name
9WO MINERVARD
c. Address �..
WAYNESBERG_ _ CH 44688 3308663435
Note: Contractor must
d. Citylroum e. State I. Zip Code g. Tai hone
P
sign this form for DLS
Wifinallon purposes
D. C@;l'fAflCa#lASt
"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
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
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 7.1.5
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."
GREG fv1RDING
1. Name
alMlil
3. PcsluorJfGla
9783759534
5. Telephone
163 RICE AVE
7. Address
MA
9. State
5/28/2020
AEROTEC
6. Represe
01053
i Page of
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