421 N Main St. Asbestos Abatement 6-11-20 #100328369d Massachusetts Departrucnt of Environmental Protection — h ------- ----------
$WP AQ 04 (ANF -001) ! 1003 8369 _
Asbestos Notification Form acheres-d ovigi
r o
P jcct Revision
r- P ject Cancellation
& Asbestos Abatement Description
1. Facility Location:
NORTHAMPTON VAMC
421 N MAIN ST
Instructions 1. All
a. Name of Facility
b. Street Address
sections of this farm
must be completed in
NORTHAMPTON NJL
,.
01053 4136844040
order to comply with
c. City/Town d.State
e.7ip Code I. Telephone
_
MaseDEP notification
requirorints of 310
JOSEEGOI-DIN
COTAR
CMR 7,15 and
9. Facility Contact Person Name
h. Facility contact person Title
Deparvi of Labor
Worksite Location:
ELDG#5 RM17
Standards (DI
notification
9. ��
i. Building Name, Win Floor, Room, etc.
requirements of 453
2. Is the facility occupied? TV- a. Yes 1-b. No
CMRS12
S. Is this a fee exempt notification (city, town, district, municipal housing authority
state facility, or
owner -occupied residential property of four units
or less)? f-- a. Yes t7 In. No
MaseDEP Use Only
_-
4. Blanket Permit Project Approval, if applicable:
Qata Received
Approval ID #
5. Non -Traditional Asbestos Abatement Work Practice
Approval,
if applicable:
Approval ID #
6. Asbestos Contractor:
AEROTECHENVIRONMENTAI.
163 RICE AVE
T Nana—�_�.----
�
b. Address
_
NORTHBOROUGH MA
01532 0783750534
c. Cityn-cum d. State
e. 70 Cade f, Telephone
I
AC00092t
h. Contract Type: W L. Written it
2. Verbal
__
I OLS License i
7. ANDERSON MARMNEZ
a. Name of Contractor's On-SiteSuperviaorlroreman
6 EDWARD T.KOWO2E.1 ^T
a. Name of Project Mondor
9. ATC GROUP SERVCES INC
a. Name of Asbestos Analytical Lab
to,
Bit 12020
a. Project Start Date tMM/DDrrfYYj
6:30AM 400 PM
c. Work Hours - Monday Thrca gh Friday
As'302444
t^ DLS Certification #
AM001903
b. DLS Certification H
AA000005 —
b. DLS' Certificeticn H
6/152020
b. End Data (MMtDD(YYYY)
6:30-8:00P
d Work Nauru Satardev 8
11. What type of project is this?
1- a. Demolition lvi b. Renovation r- c, Repair r d. other - Please specify:
Revised: f 11L3/2t113 Page L ot'4
I
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Massachusetts Department of Environmental Protection
Liiiiiiir '111111011 BWP AQ 04 (ANF -001)
". ."I Asbestos Notification Form
100 836....._.._........
9 --
Ashe tos Project q
I" 4ject:Revision
r' P jeet Cancellation
A. Asbestos Abatement Description: (cont)
12. Abatement procedures (ched", all that apply);
P a. Glove Bag r- b. Encapsulation !w c. Enclosure r d. Disposal Only I- e. CI
ry t. Full Containment r g. Other - Please Spacit'y:
13. .fob is being conducted: rJ a. Indoors r
h. Outdoors
14 a. 'rotal amount of each We of asbestos Containing materials (ACM) to be removed,
encapsulated:
5
fi50
I. Linear Fee; (Lin. Ft.)
2. Square Feet (Sq. Fl.)
It. Boiler, Breaching, Duct,
c. Transite Pipe
Tank. Surface Coatings 1. un. Ft 2. Sq. Ft
1. UU
d. Pipe Insulation 6
a. Transite Shingles
1. Lin. Ft. 2. Sq. Ft.
1. L
£. Spray -On. Fireproofing
g. Transite Panels
1, lin. Ft. 2. Sq. Ft.
TL
h. Cloths, Woven Fabrics
i. Other • Please Specify:
1 I in. Ft 2 Sq. FI.
j. Insulating Cement
CEILING MASTIC,
1, Lin.—N----2-Sq- , . . Ft.
15. Describe the decontamination system(s) to be used:
3CHAAMBEZ WASH BUCKET
16. Describe the containerization/disposal methods to comply with 310 CMB 7.15 and 4
(g):
6 MII.LDOUBLE LAC
or
CMR 6.14(2)
17. For Emergency Asbestos Operations, the MassDEP and DLS officials who. evaluated Oe emergency:
a. Name or MnsDE? Oftel T�
c. Dale of Authorization (MMIDDIYYYYI J. Waiver #
e. Name of DLu Official L Title of DL5 0fielal
q Date of Authorizatlon(IVlWDD(YYYY) h. Waiver tt
16. Do prevailing wage races as per M.G.L, c. 147, § 25, 27 or 27A- F apply to this
project?
P b. No
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Note: Tompom y
Storage of XgLcst09
containing waste
material is oily
Mowed at the Place
of business of a DLS
IIwased Asbestos
ao"anctsr or a trarsiar
siaaon toot Is
permitted by
M,tasDEf and
operated in
compliance wiU Solid
Waste RegWiflons
310 CMR 19.000
Massachusetts Department of Environmental Protection i 1003 1 33 69 _
BWP AQ 04 (ANF' -001) _.._3
Asbestos Notification Form #sbe tos Project f
r P ;ect ltevi5ion
f— P jest Canceliation
B. IF, acility Descriptions
1, Current or prior use of facility: WTCHEN1DlSH WASWNG
2. Is the facility owner -occupied residential with 4 units or less? r' a. Yes P It. No
NCATFVJh^TON VAMC
421 N MAIN ST
a. facility Orvner Name
�~
to. Address
NORThq,FTON
PAA 01053
c. CltyrTown
del. State e.2ip Code
4 NA NA
a. Name of Facility Ovrners On -Site Manager b.'
41358 44040
NA MA 00000 0000000000
c. Cltyf own a stain e. To code 1. Telavnnnt
ASR07EG_ 103RICCAVe
J'a. Name off GRneral Ccntrxitpr� b. Address
NORTHBORD PAA 01532 978375IJ534
Q. CRyrrown d. Style c. ZP Ccdo f Tdophore
ACE
65620E 5,712021
5. R'hat is the size of this facility? 21060 2
a. Square Feet G.
C. Asbestos 'Transportation & Disposal
1. Transporter of asbestos -containing waste material from site of generation:
a. Directly to Landfill or r b. To Temporary Storage Location/Transter station
AER07EC ENVIRONMENTAL 163 RICE AVE
c. blame of Transporter �� d. Address
WORniBOROUGH MA 01532 9793759634
e. Cityrrown --T� 1.State 77p::ade h.Telephone
2. If a temporary storage locatio»itnInsfer station is used, list name of transporter of asbelos containing
waste material from temporary storage location/transfer station to final disposal sit: i
Ro. 173 PICKERING ST
a. Name of Transporter u� b. Address
PORTLAND G7 01532
c. Citrt own n. Ssate e. Zip�ode
8003421342
Page 3 of 4
4'd 99£££6£9o5 001 0.19tj sad L L: L OZCZ so unr
Nofe: Contractor must
sign this form for Doe
nd , ication perposee
Massachusetts Deparhxieat of Environmental. Protection
BWP AQ 04 (ANF -001)
Asbestos Notification Form
C. Asbestos Transportation & Disposal: (cant.)
Asbstns Project 4
I" roject Revision
f iroject Cancellation
3. Name and address of temporary storage locationkransfeT station for the asbestos cont&ining waste
material: i
N4 NA
a. Tamrrsary Slorage Locetlon Nar11e b. 0
NA MA 00800 0080000000
a. Cityfrowa - ------_—�-- d. State a. Zip Code f. Telephone
4. Name and location of fmal, disposal site (asbestos landfill);
M1,MA ENTERPRICL MINERVA INV
a. Final Disposal Site Name b. Final Dlspo!
(1000 MINF_RVA RD
c..Address
WAYNES6ERG
D. Certification
"I certify that I have personally
examined the foregoing and am
familiar Wilk the information
contained in this document and
all attachments and that, based
on my inquiry of those
individuals immediately
responsibla for obtaining the
Information, I believe that the
Information is true, accurate, and
complate. 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 7.15
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
appllcahle fee Is made:"
CH 44688 3308883435
a. State E Zip Code 9. Telephone
GREG NNRDING
1. Name
CM ER
3. FosillonrMe
978$759534 i^
5. Telephone
163 RICE AVE
7. Address•v_--
MA
9. State
5!28!2020
4. Date (MMDIYYYY)
AERO TEC
015,32
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