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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100130033
ber
Decal Number
A. Asbestos Abatement Description (cont )
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or
encapsulated:
'66
a Total pipes or duds(linear M-
c.Bolter,breaching,duct,tank
surface coatings •
e.Coragated or layered paper '66
pipe insulation Lin.ft. . Sq.R.
0
6-Total other surfaces(square n)-'
Lin ft SI ft d, Insulating cement
g.Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
Lin.ft.
f.Trowel/sprayer coatings
--.' h.Tansile board.wall board
Lin.ft L Other,please specify:
l.in.0. _., Sq.ft I.Specify
14. Describe the decontamination system(s)to be used
'THREE CHAMBER DECON WITH WARM WATER SHOWER,TYVEK SUITS AND HEPA VAC
15. Describe the containerization/disposat methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g)i__.
;REWET ASBESTOS AND PACK IN DOUBLE,LABLED AND SEALED POLY BAGS
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
e Name es DEP Office' b.Tide ._....
c Date(mm/dp/yryy)or Authorization ._... d DEP Waver ft....
e.Name of DOS Official _._. _... .. f:IIOS Olrtainftle"
g Date(mmlddlWyy)of Auttionmtron h.DOS Waiver M
17. Do prevailing wage rates as per M.G.L.c. 149, §26,27 or 27A—F apply to this project? [_I.Yes_✓'.No
B. Facility Description
1. Current or prior use of facility:
2.
3.
4.
iDWELLING
Is the facility owner-occupied residential with 4 units or less? L'Yes �. No
•GREG LINDAHL • :1373 BURTS PIT RD
a Farala_y Owner Name bAddress
NORTHAMPTON 01060 .4133079645
c City/Town d Zip Cods e.Telephone Number(area rode and e>densron)
NA
a Name of Facil tr Owner's On-Site Manager b.On-Site Manai)er Address
anf001ap.doc•10/02
c CCit
y/Town own tl Zip Code a.Telephone Number(area ode and extension)
Asbestos Notification Form•Page 2 of 31
Important:
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computer.use
only the tab key
to move your
cursor-do not
use the realm
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4X:
INSTRUCTIONS
1.NI sections of this
form must be
completed In order
to comply with
DEP ratification
requirements of 310
CMR T.15
and the Division
of Occupational
Safety(DOS)
no cation
requirements of 453
CMR 6.12
C
ammo
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2
Q
• anPo0lap.doc•10/02
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100130033
Decal Number
A. Asbestos Abatement Description
1. a.Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied
residence of four units or less? o Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
GREG LINDAHL
a Name of Facility
Northampton
c.City/Town
3. Worksite Location:
BASEMENT
a.Budding Name/Building Location
4. Is the facility occupied?
6.
7.
8.
9.
MA
d Stale
b.Building#
Yes No
Blanket Decal Number
1373 BURTS HILL RD
b.Street Address_. ..
01060 4133879845
e.Zip Code f Telephone Number
c.Wing d.Floor
Asbestos Contractor:
ACE ASBESTOS REMOVALS INSULATION .101 CROSS RD
a Name b.Address
NORTHFIELD 01360 4134980201
c Qty/Town d Zip Code e.Telephone Number _- --
AC000006
l cos License Number - g. Contract Type: 1
THOMAS SHEARER
h Fac by Contact Person
THOMAS R. SHEARER
a Name of On-Site%pervuor/Foreman
RAYMOND BRESNAHAN
e Name of Pro(ed Monitor
.ENVIRONMENTAL SAMPLING AND
a.Name of Asbestos Analytical Lab
.712512011
a project start Date sta/ dyypy)
:73
c.Work hours Mon-Fri.
Verbal
SUPERVISOR -... _._..-...
i.Contact Person's Title
AS070066
__.
h.Supervisor/Foreman DOS Certification Number
AM900294
b.Project Monitor DOS Codification Number
TES TING'.. AA000132
b Asbestos Analytical Lab DOS Certhcabon Number
7127/2011
_... b.E nd Dab(mm/ yyys
NA
_.. - d Work hours Sat-Sun. _ ....
10. a.What type of project is this?
Demolition /: Renovation
.. ' Repair Other, please specify:
11. a. Check abatement procedures:
Glove bag ` Encapsulation
. Enclosure _ Disposal only
Cleanup -'Other,specify:
Full containment
b.Describe
b.Describe
12. Is the job being conducted: _' Indoors? Outdoors?
Asbestos Notification Form•Page 1 of 3•