32A-144 32 MAIN ST BP-2016-1084
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 144 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catey,ory:renovation BUILDING PERMIT
Permit# BP-2016-1084
Project# JS-2016-001853
Est. Cost: $50000.00
Ee.e.�35 0.O0 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group. ABIDE INC
Lot Size(sq. ft.): 1829.52 Owner: RENRAY REALTY LLC
Zoning: CB(100) Applicant. 32 MAIN ST PROPERTY
AT. 32 MAIN ST
Applicant Address: Phone: Insurance:
63 MAIN ST - (413) 527-2700 0
EASTHAMPTONMA01027 ISSUED ON.31912016 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE 2ND & 3RD FLR NON LOAD BEARING
MATERIAL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Shinature:
FeeType: Date Paid: Amount:
Building 3/9/2016 0:00:00 $350.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1084
APPLICANT/CONTACT PERSON 32 MAIN ST PROPERTY
ADDRESS/PHONE 63 MAIN ST EASTHAMPTON01027(413)527-2700 Q
PROPERTY LOCATION 32 MAIN ST
MAP 32A PARCEL 144 001 ZONE CB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid /74 A -3 Zh
Building Permit Filled out
Fee Paid
Typeof Construction: REMOVE 2ND&3RD FLR NON LOAD BEARING MATERIAL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
D a
r
Sign&e60woM uiIdi fcial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
Version 1.7 Commercial Building Permit May 15,2000
City of Northampton
h
Building Departmentti�
!r
Uw .. `j ' 212 Main Street�
Room 100EZ
J < 'ys orthampton, MA 01060 '
of °F Hrt lletc ,. ` one 413-587-1240 Fax 413-587-1272 I
T -'
i ,
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION'
1.1 Property Address: This section to be completed by office
X30-32 MAIN STREET. ����Pti � Map Lot. Unit.
Zane Overlay District
1
._.___ - _..... . __.,___-------- ......... _. _ ...... Elm SL District CS District ,
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
MICHAEL R BANAS/QIUHUI CHEN BANAS 1 X63 MAIN ST EASTHAMPTON, MA 01027
__._.... _.............. __.--_.... ....
Name(Print) Current Mailing Address:
(413) 52_T-2700---
Signature
27 2700Signature Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
------------ ---.. ..... ,__,,,,, ",J
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit applicant
1. Building S U Cod (a)Building Permit Fee {
2. Electrical t (b)Estimated Total Cost of
I Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection �m �� - _
6. Total=(1 +2+3+4+5) T50, 000 Check Number 3 5 6, U
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Tuildhj Commission/l spectorofBuildings ': Date
Version 1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ® Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs ElRoofing❑ Change of Use❑ Other❑
_..,._. _ ........ .. _._.
Brief Description 1REMOVAL OF NON LOAD BEARING MATERIAL. ZNV'
Of Proposed Work: t
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A AssemblyElA-1 ❑ A-2 ElA-3 ❑ 1A
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 26 I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B
M Mercantile ® 4 ❑
R Residential ® R-1 ❑ R-2 ® R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
m® ._A a....a .�
M Mixed Use Specify: £ I
S Special UseElSpecify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
y
Existing Use Group: s...._._ ,,. .,.., �.._. Proposed Use Group: 1 ,,,,,,,,,,,,
....
Existing Hazard Index 780 CMR 34):
...... _ Proposed Hazard Index 780 CMR 34): ... :
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY ,
Floor Area per Floor(sf)
1 st
3.... ,.. ...._..._...._......................_, .._,.._ ,,..._.
1 st F
2nd I _ 2nd
...... rd
rd s� n�
3
4ih €
4`h
Total Area(sf) Total Proposed New Construction(sQ
( .
Total Height(ft)
Total Height ft ®® _
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ✓❑ Private ❑ Zone • ' Outside Flood Zone❑ Municipal ❑s On site disposal system❑
Versiont.7 Commercial Building Permit May 15,2000
g. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size .......... ..... . ... _. ._.._
Frontage
Setbacks Front
I
Side L:;---,l R:L_ L:C_.. .... R: .._._. =j L____1
Rear ._ ._.........
Building Height
Bldg Square S Footage F___. % r-
g
Open Space Footage % _ -
(Lot area minus bldg&paved n f
parking)
#of Parking Spaces � -•-•••-`
Fill: i
volume&Location ___. ....
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book I i Page3 and/or Document#
....,..,...., ,, _
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location: _ ---------
_�� _ �� _.__.._ �_ �� ��
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect: / P,=o
w._ Not Applicable ElI116 PLEASANT ST., SUITE 331 EASTHAMPTON MA 01027 - w---
Name(Registrant) s�.
a., a ..........................
3
116 PLEASANT ST., SU E 331 EASTHAMPTON, MA 01027 Registration Number
Address j
d ) 529-9434_ Expiration Date
Signature elephone
9.2 Regis red Professional Engineer(s):
.............,_.,_...____._.._......., __,. .......„ ....
.....
i Be � �
i @ � F
Name Area of Responsibility
_..._.. ...,..., ...............
Address Registration Number
� t �
Signature Telephone Expiration Date
Name Area of Responsibility
k
Address Registration Number
f
Signature Telephone Expiration Date
Name Area of Responsibility
d
Address Registration Number
Signature Telephone Expiration Date
......,
i
� 1
Name Area of Responsibility
1
p 3
Address Registration Number
i
Signature Telephone Expiration Date
9.3 General Contractor
l�tAE tal�........._ ___... �:_. ' Not Applicable El
Company Name:
s
Responsible In Charge of Construction
.m ®� _e , --- a._,.e _.......
Address
1 's
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
®n
'MICHAEL R. BANAS & QIUHUI CHEP�� ® .
I
N BANAS _1, as Owner of the subject property
e, _s ..a.. _ n..
Im !
IEGFRIED PORTH ARCHITECT
here _ _wt omatters relative ork authorize by*is building permit application. ,,.T. ..�.
103/08/2016
Sig w er
Date
MICHAEL R BANAS &QIUHUI CHEN BANAS as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belie
Signed ains and.penalties'of Perla!!___....___......_..._,..,. _ . ..,.,,..__ .. .. . ........ . ._. ___...._,.. _._ _,,,,... .....;
1Ml EL ANAS HUI CHEN-BANAS
Print Na '
03/08/2016
I
Signature of ner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable p
..., j
Name of License Holder.' ___ _,,.. _,,. i.... ..... ....
License Number
..
Address Expiration Date
Signature Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§26C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No 0
' The Commonwealth of Massachusetts
Department of Industrial Accidents
vA
a
Office of Investigations
a 1 Congress Street, Suite 100
t Boston, MA 02114-2017
" www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/Individual): MICHAEL R. BANAS & QIUHUI CHEN-BANAS
Address:63 MAIN STREET
City/State/Zip: EASTHAMPTON, MA 01027 Phone #:413-527-2700
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction
2.❑■ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ■❑ Demolition
workingfor me in an capacity. employees and have workers'
Y9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _
Policy# or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a d g ' the viol tor. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of th D r in ance c et
verification.
Ido he certify ejpams an nalti of perjury t t t formation provided above is true and correct.
Sian ure: Dat e:03/08/2016
Phone#: 527-2700
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: !ZQ - F2z-
The debris will be transported by: AZ f '415 z ?20(f
The debris will be received by: ►� R c a� 6i✓ .
A/t / ,% AY
Building permit number:
Name of Permit App icant Aic A1'45 ► OH l c qbv
Date Signature of Permit Applicant
r
" Initial Construction Control Document
I�F 3 To be submitted with the building permit application by a
Registered Design Professional
for Nvork per the 8`h edition of the
Massachusetts State Building Code 780 CMR Section 107
Project Title: � 2� �/ � _ Date:_
Property Address: --
Project: Check one or both as applicable: a New construction 47Existing Construction
Project description: _��X.)ej VA 7725 --.f
c
I / � vA Registration Number: �p Expiration date. 1 am a
regisver ed design professional, and I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning:
Architectural [ J Structural [ J Mechanical
[ ] Fire Protection ( ] Electrical [ ] Other
for the above named project and that to the best of my knowledge, information,and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR),and accepted
engineering practices for the proposed project. I understand and agree that I (or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance %vith the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CNIR 107.
When required by the building official, I shall submit field/progress reports(see item 3.)together\vith pertinent
comments, in a form acceptable to the building official.
��r 4
Upon completion of the work,I shall submit to the istruction Control Document'.
Enter in the space to the right a "wet"or
electronic signature and seal: -
Phone number: 111-3 -sag_ 97J -
Building Official Use Only
Building Official Name:---____.----------------_--_---__-_,-- Permit No.: -- i we:
Version 06 1 12013
FY
Green Environmental Consulting,LLC
180 Pleasant Street
2nd Floor-Suite 213 tel/fax 413-341-3418
Easthampton, MA 01027 www.GecEnviro.com
January 5,2016
Michael R. Banas
Qiuhui Chen-Banas
Banas&Chen Realty
63 Main Street Easthampton, MA 01027
32 Main Street, Northampton, MA(2-4 Floors)
Northampton, MA
Dear Mr. Banas:
Pursuant to your request, Green Environmental Consulting, LLC(GEC) performed a limited asbestos
survey of upper floors of the above-referenced mixed-use building located in Northampton, MA
(hereafter referenced as the"building").
Fieldwork associated with the project was performed on December 18,2015 by Massachusetts-licensed
Asbestos Inspector,Adam Lesko(License#A1073071).
GEC understands that the 2nd, 3rd and 4th floors are the building are scheduled for renovation. In
accordance with state and federal asbestos regulations, asbestos-containing materials(ACM's)are
required to be identified and removed prior to disturbance.
Building Description
The building consists of a 4-story, brick building,with a full basement and has residential living space on
the 2nd-4th floors and a retail tenant space on the 1st floor. Interior finish materials in the renovation
area include linoleum sheet flooring and plaster wall and ceiling systems. Exterior finish materials include
a combination of wood and metal windows,aluminum siding and built-up asphalt-based roofing.
Asbestos Sampling/Results
Thirty(30) samples of suspect asbestos-containing materials(ACM's)were collected and submitted to
an accredited laboratory for analysis using Polarized Light Microscopy(EPA/600/R-93/116).Materials
found to contain greater than one percent asbestos are considered to be asbestos-containing materials
(ACM's).
Limited Asbestos Survey
32 Main Street, Northampton, MA (2-4 Floors)
The following materials were sampled and determined to contain trace or less than one-percent(<%)
asbestos:
. - . . . .-
f +. •.. w. -• Reference.w i. ..�•.�-w.. ..hili
e .
UrnOr s Asphalt Based Roof 1,650 01550-03A includes all roofs
Roofing Square Feet &03B
The following materials were sampled and determined not to be asbestos-containing materials:
Wall Texture Exterior-Front Entry 01550-01A, 01B&OIC
Silver Roofing Paint Roofs 01550-02A&02B
Brown Window Caulk Exterior-North (brown metal windows at front 01550-04A&04B
of building)
Wood Window Glaze 2nd,3rd and 4th Floors(above interior doors 01550-05A, 0513&
(Interior) and by stairway) 05C
Gray/Black Linoleum 2nd Floor-Southwest 01550-06A&06B
Tan Siding Paper w/Foil Exterior-South (under aluminum siding) 01550-07A &07B
Wood Window Glaze 4th Floor-South 01550-OBA&08B
Plaster Skim Coat 2nd,3rd,4th Floors 01550-09A, 09B, 09C,
09D&09E
Plaster Base Coat 2nd,3rd,4th Floors 01550-10A,1013,IOC,
IOD,10E,1OF&IOG
Refer to Attachment No. 1 for asbestos laboratory results, including detailed descriptions of sampling
locations, as well as chain-of custody records for samples collected.Asbestos bulk samples were
collected in a statistically random manner,per EPA guidelines.
Page 2 of 4
Limited Asbestos Survey
32 Main Street, Northampton, MA (2-4 Floors)
Limitations
This report is intended for the sole use of Michael Banas. This report is not intended to serve as a
bidding document nor as a project specification and actual site conditions and quantities should be field-
verified. The`scope of services performed in execution of this evaluation may not be appropriate to
satisfy the needs of other users, and use or re-use of this document,the findings,conclusions, or
recommendations herein is at the risk of said user. Although a reasonable attempt has been made to
locate suspect asbestos-containing materials(ACM's) in the areas identified,the inspection techniques
used are inherently limited in the sense that only full demolition procedures will reveal all building
materials of a structure and, therefore,all areas of potential ACM.
GEC's inspection did not include the following areas:
•1st Floor and Basement
• Concealed areas(interior of walls/ceilings)
• Electrical systems and/or components were not included in GEC's survey due to the safety
issues inherent with sampling such systems.
The Massachusetts Department of Environmental Protection (DEP), as well as the U.S. Environmental
Protection Agency(EPA)currently recognize Polarized Light Microscopy(PLM)analysis as an
acceptable analytical method for determining the Asbestos content in non-friable, organically bound
(NOB) materials. However,comparative studies between PLM analysis and Transmission Electron
Microscopy(TEM)analysis have shown that PLM analysis may yield false negative analytical results for
NOB's such as floor tiles.
GEC recommends that, prior to demolition activities,one sample from each homogeneous area of mastic
and other non-friable organically bound (NOB) materials that originally tested negative by PLM undergo
confirmatory analysis by TEM, utilizing ELAP-198.4 TEM Method for Identifying and Quantifying Asbestos
in NOB bulk samples.
Conclusions/Recommendations
Roofing materials were determined to contain trace or less-than one-percent asbestos.Although
materials that contain <1%asbestos are not by definition asbestos-containing materials, certain
regulatory requirements still apply. These requirements include the Occupational Safety and Health
Administration's (OSHA) employee exposure requirements and MassDEP regulations for"Asbestos-
Containing Waste Material"(ACWM). ACWM is not subject to MassDEP notification requirements but is
required to be managed as prescribed by 310 CMR 7.15(15)through 310 CMR 7.15(18).
Any suspect asbestos-containing material that is discovered during building renovation/demolition that
is not included in this report should be assumed to contain asbestos until further bulk sampling and
analysis is performed.
Page 3 of 4
Limited Asbestos Survey
32 Main Street, Northampton, MA (2-4 Floors)
If you have any questions regarding this survey or the sampling and/or analytical techniques employed,
please contact us at(413) 341-3418.
Sincerely,
Green Environmental Consulting, LLC
AIL
Adam Lesko
President
Page 4 of 4
A.
EMSL Analytical, Inc. EMSLOrder: 131507279
7 Constitution Way,Suite 107 Woburn,MA 01801 Customer ID: GECL78
Tel/Fax: (7$1)933-8411 /(781)933-8412 Customer PO:
http://www.EMSL.com/bostonlab@emsl.com Project ID:
Attention: Mary McCarthy Phone: (413)341-3418
Green Environmental Consulting, LLC Fax: (413)341-3419
180 Pleasant St Received Date: 12/21/2015 8:45 AM
2nd Floor,Suite 213 Analysis Date: 12/23/2015
Easthampton,MA 01027 Collected Date: 12/18/2015
Project: 01550132 Main Street, Northampton, MA
Test Report:Asbestos Analysis of Bulk Materials via EPA 600/R-93/116 Method using Polarized
Light Microscopy
Non-Asbestos Asbestos
Sample Description Appearance %Fibrous %Non-Fibrous %Type
01550-01A Exterior-Front Entry- White 3%Fibrous(Other) 97%Non-fibrous(Other) None Detected
Wall Texture Non-Fibrous
13150 72 79-0001 Homogeneous
01550-01B Exterior-Front Entry- White 3%Fibrous(Other) 97%Non-fibrous(Other) None Detected
Wall'Texture Non-Fibrous
131507279-0002 Homogeneous
01550-OIC Exterior-Front Entry- White 5%Fibrous(Other) 95%Non-fibrous(Other) None Detected
Wall Texture Non-Fibrous
131507279-0003 Homogeneous
01550-02A 1st Floor-Roof-Silver Silver 100%Non-fibrous(Other) None Detected
Roofing Paint Non-Fibrous
131507279-0004 Homogeneous
01550-02B 3rd Floor-Roof-Silver Silver 100%Non-fibrous(Other) None Detected
Roofing Paint Non-Fibrous
131507279-0005 Homogeneous
01550-03A 1st Floor-Roof- Black 30%Cellulose 66%Non-fibrous(Other) <1%Chrysotile
Built-up Asphalt Fibrous 4%Glass
131507279-0006 Based Roofing Homogeneous
01550-03B 2nd Floor-Roof- Black 30%Cellulose 60%Non-fibrous(Other) <1%Chrysotile
Built-up Asphalt Fibrous 10%Glass
131507279-0007 Based Roofing Homogeneous
01550-04A Exterior-3rd Floor NW Brown 100%Non-fibrous(Other) None Detected
-Brown Window Non-Fibrous
131507279-0008 Caulk Homogeneous
01550-04B Exterior-3rd Floor NE Brown 100%Non-fibrous(Other) None Detected
-Brown Window Non-Fibrous
131507279-0009 Caulk Homogeneous
01550-05A 4th Floor-Stairway- Brown 100%Non-fibrous(Other) None Detected
Wood Window Glaze Non-Fibrous
131507279.0010 (Interior) Homogeneous
01550-05B 4th Floor-Middle Brown 100%Non-fibrous(Other) None Detected
Room(Above Door)- Non-Fibrous
131507279-0011 Wood Window Glaze Homogeneous
(Interior)
01550-05C 2nd Floor-NW Room Brown 100%Non-fibrous(Other) None Detected
(Above Door)-Wood Non-Fibrous
131507279-0012 Window Glaze Homogeneous
(Interior)
01550-06A 2nd Floor-West Brown/Gray/Black 35%Cellulose 50%Non-fibrous(Other) None Detected
Closet-Gray/Black Non-Fibrous 15%Synthetic
131507279-0013 Linoleum Homogeneous
01550-06B 2nd Floor-SW Room- Brown/Gray/Black 35%Cellulose 55%Non-fibrous(Other) None Detected
Gray/Black Linoleum Fibrous 10%Synthetic
131507279-0014 Homogeneous
01550-07A Exterior-South 2nd Tan/Silver 60%Cellulose 40%Non-fibrous(Other) None Detected
Floor-Tan Siding Fibrous
131507279-0015 Paper w/Foil Homogeneous
01550-07B Exterior-South 4th Tan/Silver 70%Cellulose 30%Non-fibrous(Other) None Detected
Floor-Tan Siding Fibrous
131507279-0016 Paper w/Foil Homogeneous
Initial Report From:12/24/2015 12:42:51
PLM-1.65 Printed:12/24/2015 12:42 PM Page 1 of 2
AL
EMSL Analytical, Inc. EMSL Order: 131507279
7 Constitution Way,Suite 107 Woburn,MA 01801 Customer ID: GECL78
Tel/Fax: (781)933-8411 /(781)933-8412 Customer PO:
http://www..EMSL.com/bostonfab@emsl.com Project ID:
Test Report:Asbestos Analysis of Bulk Materials via EPA 600/R-93/196 Method using Polarized
Light Microscopy
Non-Asbestos Asbestos
Sample Description Appearance %Fibrous %Non-Fibrous %Type
01550-08A 4th Floor-SW-Wood Brown 100%Non-fibrous(Other) None Detected
Window Glaze Non-Fibrous
131507279-0017 Homogeneous
01550-08B 4th Floor-SE-Wood Brown 100%Non-fibrous(Other) None Detected
Window Glaze Non-Fibrous
131507279-0019 Homogeneous
01550-09A 3nd Floor-SE Room Tan 100%Non-fibrous(Other) None Detected
Wall'-Plaster Skim Non-Fibrous
131507279-0019 Coat Homogeneous
01550-09B Stairs-2nd Floor to Tan 100%Non-fibrous(Other) None Detected
3rd Floor-Plaster Non-Fibrous
131507279-0020 Skim Coat Homogeneous
01550-09C 3rd Floor-NE Room Tan 100%Non-fibrous(Other) None Detected
Ceiling-Plaster Skim Non-Fibrous
131507279-0021 Coat Homogeneous
01550-09D Stairs-Exterior to 2nd Tan 100%Non-fibrous(Other) None Detected
Floor-Plaster Skim Non-Fibrous
131507279-0022 Coat Homogeneous
01550-09E 4th Floor-SE Room Tan 100%Non-fibrous(Other) None Detected
Ceiling-Plaster Skim Non-Fibrous
131507279-0023 Coat Homogeneous
01550=10A 3rd Floor-SE Room Gray 3%Hair 97%Non-fibrous(Other) None Detected
Wall-Plaster Base Fibrous
131507279-0024 Coat Homogeneous
01550-10B Stairs-2nd Floor to Gray 3%Hair 97%Non-fibrous(Other) None Detected
3rd Floor-Plaster Fibrous
131507279-0025 Base Coat Homogeneous
01550-10C 3rd Floor-NE Room Gray 2%Hair 98%Non-fibrous(Other) None Detected
Ceiling-Plaster Base Fibrous
131507279-0028 Coat Homogeneous
01550-10D Stairs-Exterior to 2nd Gray 2%Hair 98%Non-fibrous(Other) None Detected
Floor-Plaster Base Fibrous
131507279-0027 Coat Homogeneous
01550-10E 4th Floor-SE Room Gray 3%Hair 97%Non-fibrous(Other) None Detected
Ceiling-Plaster Base Fibrous
131507279-0028 Coat Homogeneous
01550-10F 4th Floor-Middle Gray 5%Hair 95%Non-fibrous(Other) None Detected
Room Ceiling- Fibrous
131507279-0029 Plaster Base Coat Homogeneous
01550-10G 3rd Floor-East Closet Gray 5%Hair 95%Non-fibrous(Other) None Detected
-Plaster Base Coat Fibrous
131507179-0030 Homogeneous
Analyst(s)
Alexander Maxinoski(13) Alexander Maxinoski,Asbestos Laboratory Manager
Michael Mink(17) or Other Approved Signatory
EMSI,maintains liability limited to copt of analysis. This report relates only to the samples reported and may not be reproduced,except in full,without written approval by EMSL. EMSL bears no
responsibility for sample collection activities or analytical method limitations. Interpretation and use of test results are the responsibility of the client. This report must not be used by the client to claim
product certification,approval,or endorsement by NVLAP,NIST or any agency of the federal government. Non-friable organically bound materials present a problem matrix and therefore EMSL
recommends gravimetric reduction poor to analysis. Samples received in good condition unless otherwise noted. Estimated accuracy,precision and uncertainty data available upon request.Unless
requested by the client,building materials manufactured with multiple layers(i.e.linoleum,wallboard,etc.)are reported as a single sample.Reporting limit is 1%
Samples analyzed by EMSL Analytical,Inc.Woburn,MA NVLAP Lab Code 101147-0,CT PH-0315,MA AA000188,RI AAL-107T3,VTAL998919,Maine Bulk Asbestos BA039
Initial Report From:12/24/2015 12:42:51
PLM-1,65 Printed:12/24/2015 12:42 PM Page 2 of 2
OrderID: 131507279
131507279
Pagel
Analysis Type:
Asbestos Chain of Custody PLM
i Record
»around Time:ls;r Hour
Green Environmental Consulting,LLC
180 Pleasant Street-Suite 213
Easthampton,MA 010.27
Proiect Info: Send Results To:
Project Name: [l-ary
voice to: Cary
esults to:
32 Main Street, Northampton, MA McCarthy McCarthy
1roject Number: Return Samples?: irory(EDgecenviro.com
mail to:
01550
roject Description: Comments/Special Phone: �u
Pre-Renovation Asbestos Inspection instructions: 4.13)341-3418
Fax:
(413) 341-3418
Sample Number Sample Location Sample Description
01550-t71A Exterior-Front Entry Wall Texture
01550-018 Exterior-Front Entry Wall Texture
01550-OIC Exterior-Front Entry all Texture
071550-D2A Ist Floor-Roof Silver Roofing Paint
01550-02B 3rd Floor-Roof Silver Roofing Paint
01550-03A lst Floor-Roof Built-up Asphalt Based Roofing
I
01550-03B 2nd Floor-Roof Built-up Asphalt Based Roofing
01550-04A Exterior-3rd Floor NW Brown Window Caulk
Sam led B Date: Received By: iii?! Date/Time'
RAlinhed.,Y Date/Time: Received in Lab By: f � Date/Time:
y
t' a 1`lscJ 1 �y17Page 1 Of 4
OrderID: 131507279
3 5 0 7 2 7 9
Page 2 (J
nalysis Type:
Asbestos Chain of Custody k
PLM
Record
Unaround Time:
96 Hour
Green Environmental Consulting, LLC
180 Pleasant Street-Suite 213
Easthampton,MA 01027
Proiect Info: Send Results To:
Project Name: nvoice to Results to:
32 Main Street, Northampton, MA V-11ary McCarthy Iary McCorthv
rroject Number: Return Samples?: Email to:
1550 1 Mary(sgecenvlro.com
3roject Description: Comments/Special Phone:
Pre-Renovation Asbestos fnspection Instructions: (413)341-3418
Fax:
(413) 341-3418
Sample Number SamRle Location Sample Description
01550-048 Exterior-3rd Floor NE Brown Window Caulk
01550-05A 4th Floor-Stairway Wood Window Glaze(interior)
01550-05B 4th Floor-Middle Room(above Wood Window Glaze(interior)
door) I I
2nd Floor-NW Room(aboveood Window Glaze(interior)
door) 7_7
01550-06A 2nd Floor-West Closet ray/Black Linoleum
01550-06B 2nd Floor-SW Room Gray/Black Linoleum
01550-07A Exterior-South 2nd Floor Tan Siding Paper w/Foil
01550-07B Exterior-South 4th Floor Tan Siding Paper w/Foil
Sam
Sarnibidd By: Date: Received By: Date/Time:
Re1i quish Date/Time: Received in Lab By: Date/Time:
Page 2 Of 4
....................................................................................................................................................................................................................................................................
OrderID': 131507279 131507279
000 mft44�� Page 3
na ysis Type:
Asbestos Chain of Custody PLM
Record urnaround Time:
\��4w 6 Hour
Green Environmental Consulting, LLC
180 Pleasant Street-Suite 213
Easthampton,MA 01027
Proiect Info: Send Results To:
Project Name: Invoice to: Results to:
32 Main Street, Northampton, MA ary McCarthy Mary McCarthy
Iroject Number: Return Samples?: Email to:
01550 ary@gecenviro.eom
roject Description: Comments/special Phone:
Pre-Renovation Asbestos Inspection Instructions: (413) 341-3418
Fax:
(413)341-3418
Sample Number Sample Location Sample Description
01550-08A 4th Floor-SW Wood Window Glaze
01550-088 4th Floor-SE Wood Window Glaze
01550-09A 3rd Floor-SE Room Wail Plaster Skim Coat
01550-098 Stairs-2nd Floor to 3rd Floor Plaster Skim Coat
01550-09C 3rd Floor-NE Room Ceiling Plaster Skim Coat
01550-09D Stairs-Exterior to 2nd Floor Plaster Skim Coat
01550-09E 4th Floor-SE Room Ceiling Plaster Skim Coat
01550-IOA 3rd Floor-SE Room Wall Plaster Base Coat
Sam;e By: Date: Received By: Date/Time:
ka- 17 -1 ?
Reli ui hed By: Date/Time: Received in Lab By: Date/Time:
Page 3 Of 4
OuderIU: 131507279 131507279
Page 4
AN
Analysis Type:
Asbestos Chain of Custody PLM
Record
urnaround Time:
6 Hour
Green Environmental Consulting, LLC
180 Pleasant Street-Suite 213
Easthampton,MA 01027
Proiect Info: Send Results To:
j Project Name: Invoice to: Results to:
r
32 Main Street, Northampton,MA Mary McCarthy Mary McCarthy
Iroject Number: Return Samples?: Email to: T
01550
ary@gecenviro,com
roject Description: Comments/Special Phone:
Pre-Renovation Asbestos Inspection Instructions: (413)341-3418
Fax:
413)341-3418
Sample Number Sample Location Sample Description
01550-10B Stairs-2nd Floor to 3rd Floor Piaster Base Coat
01550-10C 3rd Floor-NE Room Ceiling Plaster Base Coat
01550-10D Stairs-Exterior to 2nd Floor Plaster Base Coat
O1S50-10E 4th Floor-SE Room Ceiling =
ase Coat
f
01550-IOF 4th Floor-Middle Room Ceiling Plaster Base Coat
01550-10G 3rd Floor-East Closet Plaster Base Coat
SMBY: Date: Received By: Date/Time:
Re h By: Date/Time: Received in Lab By: Date/Time: "
7 (C (� I-(
lb,30
Page 4 Of 4
Table of Contents
(AO;01, 0 P y
ANALYTICAL LABORATORY
39 Spruce Stree ' Longmeadow,MA 01028`FAX 413/525-6405'TEL.413/525-2332
GEAR
January 12,2016
Jerry Gray
Abide Environmental
P.O.Box 886
East Longmeadow,MA 0 102 8
Project Location:Main St.Northapton,MA
Client Job Number:
Project Number:Seney-1
Laboratory Work Order Number: 16AO122
Enclosed are results of analyses for samples received by the laboratory on January 6,2016.If you have any questions concerning
this report,please feel free to contact me.
Sincerely,
Aaron L.Benoit
Project Manager
Page 1 of 12
Table of Contents
Table of Contents
Sample Summary 3
Case Narrative 4
Sample Results 5
16AO 122-01 5
Sample Preparation Information 6
QC Data 7
TCLP-Metals Analyses 7
B139403 7
Flag/Qualifier Summary 8
Certifications 9
Chain of Custody/Sample Receipt 10
Page 2� of 12�
Table of Contents
ANALYTICAL LABORATORY
39 Spruce StreetEast Longmeadow,MA 01028"FAX 413/525-6405'TEL.413/525-2332
Abide Environmental
P.O.Box 886 REPORT DATE: 1/12/2016
East Longmeadow,MA 01028 PURCHASE ORDER NUMBER: Seney.Tom
ATTN:Jerry Gray
PROJECT NUMBER: Seney-1
ANALYTICAL SUMMARY
WORK ORDER NUMBER: 16A0122
The results of analyses performed on the following samples submitted to the CON-TEST Analytical Laboratory are found in this report.
PROJECT LOCATION: Main St.Northapton,MA
FIELD SAMPLE# LAB ID: MATRIX SAMPLE DESCRIPTION TEST SUB LAB
Plaster/Wood(painted) 16A0122-01 Product/Solid SW-8461311
SW-846 601OC
Page 3 of 12
Table of Contents
n"NW
ANALYTICAL LABORATORY
39 Spruce Street'East Longmeadow,MA 01028'FAX 413/525-6405"TEL.413/525-2332
CASE NARRATIVE SUMMARY
All reported results are within defined laboratory quality control objectives unless listed below or otherwise qualified in this report.
The results of analyses reported only relate to samples submitted to the Con-Test Analytical Laboratory for testing.
I certify that the analyses listed above,unless specifically listed as subcontracted,if any,were performed under my direction according to the approved methodologies listed
in this document,and that based upon my inquiry of those individuals immediately responsible for obtaining the information,the material contained in this report is,to the
best of my knowledge and belief,accurate and complete.
Wg
Johanna K.Hartington
Manager,Laboratory Reporting
Page 4 of 12
Table of Contents
Awwl
ANALYTICAL LABORATORY
39 Spruce Street`East Longmeadow,MA 01028'FAX 413/525-6405`TEL.413/525-2332
Project Location: Main St.Northapton,MA Sample Description: Work Order: 16A0122
Date Received: 1/6/2016
Field Sample#: Plaster/Wood(painted)
Sample ID: 16A0122-01 Start Date/Time:1/6/2016 10:00:OOAM
Sample Matrix: Product/Solid Stop Date/Time: 1/6/2016 10:15 OOAM
TCLP-Metals Analyses
Date Date/Time
Analyte Results RL Units Dilution Flag/Qual Method Prepared Analyzed Analyst
Lead 0.30 0.010 mg/L 1 SW-8466010C 1/8/16 1/11/1615:13 AME
Page 5 of 12
Table of Contents
moE-5
_NW,
ANALYTICAL LABORATORY
39 Spruce Street'East Longmeadow,MA 01028'FAX 413/525-6405'TEL.413/525-2332
Sample Extraction Data
Prep Method:SW-846 3010A-SW-846 6010C Leachates were extracted on 1/7/2016 per SW-846 1311 in Batch B139317
Lab Number[Field IDI Batch Initial lmLl Final lmLl Date
16A0122-01[Plaster/Wood(painted)] B139403 50.0 50.0 01/08/16
Page 6 of 12
O Table of Contents
aotest
ANALYTICAL LABORATORY
39 Spruce Street*East Longmeadow,MA 01028'FAX 413/525-6405'TEL.413/525-2332
QUALITY CONTROL
TCLP-Metals Analyses-Quality Control
Reporting Spike Source %REC RPD
Analyte Result Limit Units Level Result %REC Limits RPD Limit Notes
Batch B139403-SW-846 3010A
Blank(B139403-BLKI) Prepared:0 1/08/16 Analyzed:01/11/16
Lead ND 0.010 mg/L
LCS(B139403-BSI) Prepared:01/08/16 Analyzed:01/11/16
Lead 0.461 0.010 mg/L 0.500 92.3 80-120
LCS Dup(B139403-BSDI) Prepared:01/08/16 Analyzed:01/11/16
Lead 0.467 0.010 rng/L 0.500 93.3 80-120 1.13 20
Page 70f 12
Table of Contents
co,n#-.c to"
ANALYTICAL LAaoRA7URY
39 Spruce Street'East Longmeadow,MA 01028'FAX 413/525-6405'TEL.413/525-2332
FLAG/QUALIFIER SUMMARY
' QC result is outside of established limits.
t Wide recovery limits established for difficult compound.
$ Wide RPD limits established for difficult compound.
# Data exceeded client recommended or regulatory level
RL Reporting Limit
DL Method Detection Limit
MCL Maximum Contaminant Level
Percent recoveries and relative percent differences(RPDs)are determined by the software using values in the
calculation which have not been rounded.
No results have been blank subtracted unless specified in the case narrative section.
Page 8 of 12
iel f,0 Table of Contents
%wn"te4&
AMALYTICAL LABORATORY
39 Spruce Street'East Longmeadow,MA 01028'FAX 413/525-6405`TEL.413/525-2332
CERTIFICATIONS
Certified Analyses included in this Report
Analyte Certifications
SW-846 60100 in Water
Lead NY,CT,ME,NC,NH,VA
The CON-TEST Environmental Laboratory operates under the following certifications and accreditations:
Code Description Number Expires
A1HA AIHA-LAP,LLC 100033 02/1/2016
MA Massachusetts DEP M-MA100 06/30/2016
CT Connecticut Department of Publilc Health PH-0567 09/30/2017
NY New York State Department of Health 10899 NELAP 04/1/2016
NH-S New Hampshire Environmental Lab 2516 NELAP 02/5/2016
RI Rhode Island Department of Health LA000112 12/30/2016
NC North Carolina Div.of Water Quality 652 12/31/2016
NJ New Jersey DEP MA007 NELAP 06/30/2016
FL Florida Department of Health E871027 NELAP 06/30/2016
VT Vermont Department of Health Lead Laboratory LL015036 07/30/2016
WA State of Washington Department of Ecology C2065 02/23/2016
ME State of Maine 2011028 06/9/2017
VA Commonwealth of Virginia 460217 12/14/2016
NH-P New Hampshire Environmental Lab 2557 NELAP 09/6/2016
Page-9-07-12
test&Ptione:413.525-2332 CHAIN OF CUSTODY RECORD 39 Spruce Street Page (' of__L
conn
Fax:413-525-6"5East longmeadow,MA 01028
Email:info@contestlabs.comIL"a k #Of Containers
ANALYTICAL LABORATORY
www.contestiabs.com C • Preservation
Company Name: y CY Telephone: ?i 5�i 4� L *"Container Code
` t �
ANALYSIS REQUESTED Address: Pr 1ect#
Dlssofv&d Metals
a_sLp Client Pat _ � p Find iFiliered
(check a0 tappN!
Attention: O Cab to hiker
FAX / EM1AfL OWEBSrTE
Project Location: MAI1V ax# 1 `` gil - Z'S' Q ?O
++ "'�Coltt Colie
Sampled B Email:
(' JC: - L A�attmrgtass
p
Project Proposal Provided?(for billing urposes) Format OPDF ijEXCEL CGIS pl
O Yes O OTHER �2. ST$5te1Ue
proposal date `
Coll BCtion 10 "Enhanced Data Package" V Yidt.'
Con-Test Lab ID Beginning Ending •f� L StSUt111t1a cart
Client Sample ID!Description lancwo !� r=tecuar
''�"�N�•a" Date tine Datefrime Composite Grab Cade
G Q Q lb" AM
*"Preservation
i n4rr C�
Va .
e N J � U rhf�+N(Lr+eAdd:
' 5�Sutfiiirk lkcit!`;.
B=SodFulrl b'esutfate
X=Nahydrazide
X
T*Na'thiosutfate
r� 5s".Gs�ti4fatt �i �rOtfier
y t f
s � r
f� t f _ G1Af-grrfurlt(wat'er ''.
,1 r t L?i � f, �f Y lArilStE'IAl�ter .
Comments: Please use the following codes to lat Con Test know if a specific sample DWS rfr[nkt ,xtater.:
may be high in concentration in tvlatrix/Ccnc.Code Box: A
---------------------------------- S=sail/solid
H-Hl h:M-Medium;L-Low, C-Clean; U-Unknovm SL=Sludge
by: ? Lla< Turnaround Detection Limit R uirements C other
7-Day istassecnuselts: Is � ° P.
rINCORRECT,
by:(sigratu DatetTme: O 10-0ay Q MCP Form Required
t O Other Q RCP Form Required
ed by:(signature) Date/Time: RUSH t Connec6cue Q MA State QW Form Required PWSID A—_- m
O 124-Hr 17 148-Hr �4Q,•�«a,o- NEL.AC&AIHA-LAP,LLC Cr
, Accredited O
by:(signature) DatetTime: O t72-Hr In —
�,� �'Rie a provai Other. „ WBE/DBE Certi#ieq oROUND TIME STARTS AT 9:00 AM.THE DAY AFTER SAMPLE RECEIPT UNLESS THERE ARE QUESTIONS ON YOUR CHAIN. IF THIS FORM IS NOT FILLED OUT COMPLETELY OR
TURNAROUND TIME WILL NOT START UNTIL ALL QUESTIONS ARE ANSWERED BY OUR CLIENT. PLEASE BE CAREFUL NOT TO CONTAMINATE THIS DOCUMENT
Cn
Table of Contents
39 Spruce St.
test
East Longmeadow,MA.01028 ton■+
o'
P:413-525-2332 ANALYTICAL LABORATORY
F:413-525.6405 Page 1 of 2 � °
www.contestlabs.com Sample Receipt Checklist
F
CLIENT NAME:
_ RECEIVED BY: ^�� DATE:
1) Was the chain(s)of custody relinquished and signed? es No No CoC Included
2) Does the chain agree with the samples? Yes No
If not,explain:
3) Are all the samples in good condition? Yes No
If not,explain:
4) How were the samples received:
On Ice ❑ Direct from Sampling �� Ambient (Q In Cooler(s) ❑
Were the samples received in Temperature Compliance of(2-6°C)? Yes Na /A
Temperature°C by Temp blank Temperature°C by Temp gun
5) Are there Dissolved samples for the lab to filter? Yes No
Who was notified Date Time
6) Are there an US or SHORT HOLDING TIME samples? Ye�y No
Who was notified Date Time
Permission to subcontract samples? Yes No
7) Location where samples are stored: /-- (Walk-in clients only)if not already approved
Client Signature:
8) Do all samples have the proper Acid pH: Yes No N/A
9) Do all samples have the proper Base pH: Yes NoN/A
10)Was the PC notified of any discrepancies with the CoC vs the samples: Yes No /A -
Containers received at Con-Test
#of containers #of containers
1 Liter Amber J 8 oz amber/clear jar
500 mL Amber 4 oz amber/clear jar
1 ..
250 mL Amber(8oz amber) 2 oz amber/clear jar
1 Liter Plastic Plastic Ba /Zi loc
500 mL Plastic SOC Kit
250 mL plastic Non-ConTest Container
� f
40 mL Vial-type listed below Perchlorate Kit
Colisure/bacteria bottle Flashpoint bottle
Dissolved Oxygen bottle Other lass jar
Encore Other
Laboratory Comments:
40 mL vials: #HCI #Methanol Time and Date Frozen:
Doc#2:rr:< :- <:`'::':`:#Bisulfate #DI Water
Thiosulfate Unpreserved
Page 11 of 12
Table of Contents
3
Page 2of2
Login Sample Receipt Checklist i
(Rejection Criteria Listing-Using Sample Acceptance Policy)
Any False statement will be brought to the attention of Client
Question Answer True/False Comment
T/F/NA
1 The cooler's custody seal, if present, is intact.
2)The cooler or samples do not appear to have T
been compromised or tampered with.
3)Samples were received on ice.
4 Cooler Temperature is acceptable.
5)Cooler Temperature is recorded. LA
6 COC is filled out in ink and legible.
7 COC is filled out with allpertinent information.
8 Field Sampler's name present on COC. !
9)There are no discrepancies between the
sample IN on the container and the COC.
10 Samples are received within Holding Time.
11)Sample containers have legible labels.
12)Containers are not broken or leaking.
13 Air Cassettes are not broken/open.
14)Sample collection date/times are provided.
15 Appropriate sample containers are used.
16)Proper collection media used. T
17 No heads ace sample bottles are completely filled. 1
18)There is sufficient volume for all requsted
analyses, including any requested MS/MSDs.
19 Trip blanks provided if applicable.
20)VOA sample vials do not have head space or
bubble is<6mm 1/4" in diameter.
21)Samples do not require splitting or compositin .
Who notified of False statements? Date/Time:
Doc#277 Rev.4 August 2013 Log-In Technician Initials: DatelTime:
Page 12 of 12
ACC> CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDtYYYY)
03/10/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
Laura O'Hara
JAMES J. DOWD AND SONS INS AGENCY INC N x . (413)437-1020
WN ac,
No):
E-MAIL omd
d
h
loara ow .c _
ADDRESS: @ _
14 Bobala Road INSURER{S}AFFORDING COVERAGE NAIC#
HOLYOKE MA 01041 INSURER A: AIM MUTUAL INS CO 33758
INSURED INSURER B: _
ABIDE INC INSURERC:
INSURER D: _
P O BOX 886 INSURER E:
EAST LONGMEADOW MA 01028 INSURER F:
COVERAGES CERTIFICATE NUMBER: 36280 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS
LTR I POLICY NUMBER MWDD MM/DD
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS MADEEl OCCUR _15AAMA(ME TO—RENTED
PREMISES Ea occur ence $
MED EXP(Any one person) $
N/A _PERSON AL&ADVINJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _
POLICY❑PRO JEGT LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident _
ANY AUTO BODILY INJURY(Per person) $
— ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTYDAMAGE $
HIRED AUTOSAUTOS Per accident)q I I $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
X STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
A OFFICER/MEMBEREXCLUDED? NIA NIA N/A AWC40070132782015A 09/0112015 09/01/2016
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
Ifes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
N/A
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/lwd/workers-compensation/investigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Northampton Louis Hasbrouk Building Commissioner ACCORDANCE WITH THE POLICY PROVISIONS.
212 Main Street
AUTHORIZED REPRESENTATIVE
(~ - -C1r
Northampton MA 01060
Danleiell M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA
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