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10 Asbestos Notification Form 2011 Important: When filling out forms on the computer.use only the tab key to move your cursor-do not use the return key. 1 STRUCTIONS Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • (100120341 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? GI Yes ❑No b.Provide blanket decal number if applicable: 2. Facility Location: 'HAMPSHIRE HEIGHTS a.Name of Facility 'Northampton c.City/Town 3. Worksite Location: 1 All sections of this I ml must be completed in order t comply with 4 DEP notification requirementS of 310 5 CMR7.15 and the Division of Occupational Safety(DOS) notification requirements or453 CMR 6.12 0 ca 0 0 0 LL z Q 7. 8. 9. !HAMPSHIRE HEIGHTS a.Building Name/Building Location [MA d.State 'BLDG 12 Blanket Decal Number 110 JACKSON STREET b.Street Address 101060 e.Zip Code 14015692277 Telephone Number b.Building# c.Wing Is the facility occupied? 151 Yes ❑No Asbestos Contractor: 1ST FLOOR d.Floor 1APT'S A&D 1 e.Room 'ACCUTECH INSULATION &CONTRACTING II a.Name 'LUDLOW c.City/Town (AC000005 f.DOS License Number JON HITE 101056 d.Zip Code J 1 1100 STATE STREET b.Address 4135835500 e.Telephone Number g Contract Type: Written ❑Verbal Contact Person "°"•°°" "'°"" ""° h.Facility 'JULIO VENTURA 1 1AS001178 a.Name of On-Site Supervisor/Foreman b Supervisor/Foreman DOS Certification Number IN/A NIA Monitor b Project Monitor DOS Certification Number a.Name of Project IN/A 1 [NIA DOS Certification Number b Asbestos Analytical Lab a.Name of Asbestos Analytical Lab 1 12/22/2011 12122/2011 .... n F nd Date I mm/ddl yvyyl 17AM-4PM c.Work hours Mon-Fri. 10 a What type of project is this? ❑ Demolition IS Renovation ❑Repair ❑Other, please specify: 11. a. Check abatement procedures: • Glove bag ❑Enclosure ❑Cleanup ❑ Full containment 12. Is the job being conducted ■ antooiapeoc•10/02 ❑Encapsulation ❑ Disposal only ❑Other,specify: [WA d.Work hours Sat-Sun. b.Describe b. Describe 7 Indoors? ^Outdoors? Asbestos Notification Form•Page 1 of 3 In SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NEG I Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120341 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or encapsulated: 0 a.Total pipes or ducts(linear ft) c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing i.Cloths,woven fabrics k.Thermal,solid core pipe insulation 4 b. I otal other surfaces(square n) Lin.ft. Lin.ft. Lin.ft. Sq.ft. Lin.ft. Sq-ft. d.Insulating cement f.Trowel/Sprayer coatings h.Transite board,wall board S h j.Other,please specify: Sq.ft. I.Specify Lin Sq.ft. Lin.n. sq.if 4 VAT 14. Describe the decontamination system(s)to be used 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY&DELIVERED IN A SEALED VEHICLI 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: N/A a.Name of DEP OTcia c.Date(mmidd/yyyy)of Authorization N/A e.Name of DOS Official NIA b.Title N/A d DEP Waiver# N/A L DOS Official Title g.Date(mnVdd/yyyyl of Authorization 17. Do prevailing wage rates as per M.G.L.c. 149, §26,27 or 27A-F apply to this project? Yes n No N/A h.DOS Waiver# ° B. Facility Description 0 LL z 1 Current or prior use of facility: RESIDENTIAL 2 Is the facility owner-occupied residential with 4 units or less? Yes • No 3 4. NORTHAMPTON HOUSING AUTHORITY a.Facility Owner Name NORTHAMPTON c.City/Town 01060 d.Zip Code JOHN CONNERS anf001ap doe•10/02 a.Name of Facility Owner s On-Site Manager WARWICK 02886 1 c.City/Town - _-- d Zip Code 149 OLD SOUTH STREET b.Address 413-584-4030 e Telephone Number(area code and extension) 3600 WEST SHORE DRIVE b.On-Site Manager Address 401-569-2277 _, e.Telephone Number(area code and extension) Asbestos Notification Form•Page 2 of 3 (NATIONAL REFRIGERATION a.Name of General Contractor 102886 d.Zip Code Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19.000 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 ji00120341 Decal Number B. Facility Description (cord.) (WARWICK c.City/Town (AIG C Contractor's Worker's Comp.Insurer 6. What is the size of this facility? 13600 WEST SHORE DRIVE b Address 1401.737-2000 e.Telephone Number(area code and extension) ( (WC5318622 I 111/4/2011 q.Policy Number (h.Exp.Date(mm/ddlyyyy) b.Number of floors ( a.Square Feet C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): 1ACCUTECH INSULATION 8 CONTRACTING, 11 1100 STATE ST. BLDG 119, PO BOX 376 a.Name of Transporter b.Address (LUDLOW ( ( 4135835500 G.City/Town d.Zip Code e.Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 3. RED TECHNOLOGIES a.Name of Transporter 1BLOOMFIELD c.City/rown a.Refuse Transfer Station and Owner c City/Town d.Zip Code (01056 ( 106002 4. MINERVA ENTERPRISES INC a Final Disposal Site Location Name 9000 MINERVA ROAD c.Final Disposal Site Address (OH e State (44688 f.Zip Code 0 • D. Certification • The undersigned hereby states,under the • penalties of perjury,that he/she has read the • Commonwealth of Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and • 310 CMR 7.15,and that the information contained in this notification is true and correct o to the best of his/her knowledge and belief. 0 p_ z a • anfoolapdoc•10/02 110 NORTHWOOD DRIVE b.Address 18602182428 e.Telephone Number Address ( e.Telephone Number b.Final Disposal Site Location Owner's Name WAYNESBURG d.City/Town g.Telephone Number (FAITH LEMAY a.Name (ADMIN ASSIST c.Position/Title 14135835500 e.Telephone Number 100 STATE ST. BLDG 1 Address q. (LUDLOW h.City/Town J ITH LEM b Authorized Signature 2/4/2011 d.Date(mm/dd/WVY) ACCUTECH INSULATION i.Representing 19,PO BOX 376 ' 101056 ( I.Zip Code Asbestos Notification Form•Page 3 of 3• nportant: ?hen filling out inns on the omputer,use my the tab key 1 move your ursor-do not me the return ey. Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100120344 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? 101 Yes ❑No b.Provide blanket decal number if applicable: 2. Facility Location: Name of Facil INSTRUCTIONS 3- 1.All sections of this form must be completed in order to comply with 4. DEP notification requirements of 310 5 CMR 715 and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 6.12 0 0 IN O 0 0 LL Blanket Decal Number Northampton c.citylrown Worksite Location: HAMPSHIRE a.Building Name/Building Locatton MA d.State BLDG 13 b.Building fI Is the facility occupied? Yes ❑No Asbestos Contractor: ACCUTECH INSULATION &CONTRACTING I a Name VA 01056 Zi.Code 0 JACKSON STREET b.Street Address 01060 e.Zip Code c.Wing AC000005 f.DOSE_pOS License JON HITE Facili Contact Person JULIO VENTURA a.Name of On-Site Su.e a C Telephone Number 1ST FLOOR d Floor 00 STATE STREET b.Addre ss 4135835500 �--- e.Telephone Number g. Contract Type: I Written ❑Verbal APT'S A&D e.Room Foreman o Monitor NIA a.Name of Asbestos Anal 2123/2011 cal Lab i.Contact Person's Title AS001178 b.Su.ervisoriFOreman DOS Certification Number NIA b.Pr NIA b.P___I§L_De§tjaAilaY1Qa1Lab DOS Certification 2123(2011 b.E nd Dale mml d' NIA d.Work hours Sat-Sun. I Monitor DOS Oenification Numbe a.Pro ect Start Dal 7AM-4PM c.Work hours Mon-Fri. 10. a.What type of project is this? ❑Demolition ❑Repair 12 Renovation ❑Other, please specify. 11. a. Check abatement procedures: ❑Encapsulation ❑Disposal only ❑Other, specify. (]Glove bag ❑Enclosure ❑Cleanup ❑ Full containment 12. Is the job being conducted: [ Indoors? I I Outdoors? b.Describe b.Describe ■ anf0o1ap.doc•10102 Asbestos Notification Form•Page 1 of 3 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 1100120344 Decal Nu A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or encapsulated-0 4 a. ota pipes or ducts(linear fl) c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing I.Cloths.woven fabrics k.Thermal,solid core pipe insulation 14. Describe the decontamination system(s)to be used: SEAL CRITICALS W/6 MIL POLY,PRE-CLEAN,LAY DROP CLOTH& REMOVE USING THE NE 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR o a o er su aces square 1 Lin.ft. Sq.k. 1 I Lin ft. Sq.fl. `in ft. Sq.ft. 1� Lin.ft. Lin ft. Sq.ft. d.Insulating cement L Trowel/Sprayer coatings h Transite board,wall board Other,please specify' VAT I. Specify 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY&DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: —I NIA E•0 cial __ b.Title _I N/A d.DEP Waiver G.Date(mmldtll )of Authorization N/A N/A e.Name of DOS Official NIA g.Date(mmlddlyyyy)of AptM1011Z2llnn h.DOS Waiver# N B. Facility 26,27 or 27A—F apply to this project? Yes No o . prevailing wage rates per M.G.L.c. 149, § o B- Facility Descriptioo n S N o 1. Current or prior use of facility: RESIDENTIAL 2. Is the facility owner-occupied residential with 4 units or less? yes No NORTHAMPTON HOUSING AUTHORITY 3. Facility Owner Name o NORTHAMPTON • Cit (Town JOHN CONNERS LL 4 a.Name of Facility Owner's On-Site Z WARWICK C c.City/Town anfootapeoc•19/02 01060 d Code anger 02886 d Zip Code 1 49 OLD SOUTH STREET b.Address 413-584-4030 ension e.Telephone Number area code and e 3600 WEST SHORE DRIVE b.On-Site an er Addre ss 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form•Page 2 of 3 II Tote:Transfer ;rations must amply With the tolid Waste )ivision tegulations 310 ;MR 19.000 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100120344 Decal Number B. Facility Description (cont.) 5' a.Name of General Contractor NATIONAL REFRIGERATION WARWICK c.City/Town 02886 d.Zip Code AIG f Contractors Workers Comp.Insurer 6. What is the size of this facility? 3600 WEST SHORE DRIVE b.Address 401-737-2000 e.Telephone Number(area code and extension) 11/4/2011 h.Exp.Date(mmldd/yyyy) WC5318622 q.Policy Number a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site Of necessary): 1ACCUTECH INSULATION &CONTRACTING, I a.Name of Transporter LUDLOW 01056 1100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 c.City/Town d.Zip Code e.Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 3 RED TECHNOLOGIES a. Name of Transporter BLOOMFIELD C.City/Town 06002 d Zip Code a.Refuse Transfer Station and Owner c.City/Town MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 1 d.Zip Code 1 10 NORTHWOOD DRIVE b Address 8602182428 e.Telephone Number b.Address t- e.Telephone Number 9000 MINERVA ROAD c.Final Disposal Site Address OH A State 44688 f.Zip Code • D. Certification The undersigned hereby states,under the o penalties of perjury,that he/she has read the o Commonwealth of Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. 0 LL Z C anf001ap.doc•10/02 0.Final Disposal Site Location Owner's Name WAYNESBURG d.City/Town g.Telephone Number FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 4135835500 e.Telephone Number Authorized Signature 214(2011 d.Date(mm/dd/vvW) ACCUTECH INSULATION! L Representing 100 STATE ST. BLDG 119, PO BOX 376 q.Address LUDLOW h.City/Town 01056 i Zip Code Asbestos Notification Form•Page 3 of 3 iportant: hen filling out ms on the mouton use ily the tab key move your rsor-do not a the return O. 0 ISTRUCTIONS Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 1100120346 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? • Yes ❑No b.Provide blanket decal number if applicable: 2. Facility Location: HAMPSHIRE HEIGHTS a Name of Facility Northampton c.City/Town 3. Worksite Location: All sections of this cm must be umpleted in order comply with 4. EP notification quirements of 310 5. MR 7.15 nd the Division f Occupational afety(DOS) otificafion quirements of453 :MR 6.12 0 0 N 0 U. z HAMPSHIRE HEIGHTS a.Building Name/Building Location MA d.State 'BLDG 14 b.Building if Is the facility occupied? Yes ❑No Asbestos Contractor: 12 (ACCUTECH INSULATION 8 CONTRACTING 1 a Name LUDLOW c.City/Town AC000005 f.DOS License Number 01056 d Zip Code (JON HITE h. Facility Contact Person (JULIO VENTURA 6. a Name of On-Site Supervisor/Foreman `N/A a Name of Proiect Monitor N/A Blanket Decal Number 10 JACKSON STREET b Street Address 01060 e.Zip Code c Wing (4015692277 t Telephone Number 1ST FLOOR d Floor APT'S A 8 D e.Room 100 STATE STREET b.Address 4135835500 e.Telephone Number g. Contract Type: t7 Written ❑Verbal 8' a.Name of Asbestos Analytical Lab 9. 2/23/2011 a.Pro'ect Start Date mmlddl 7AM-4PM c.Work hours Mon-Fri. Contact Person's Title AS001178 b.Supervisor/Foreman DOS Cedificatlon Number 'N/A b.Proiect Monitor DOS Certification Number N/A 10 a What type of project is this? ❑ Demolition ❑ Repair 0 Renovation ❑Other, please specify: 11. a. Check abatement procedures: Glove bag ❑Encapsulation ❑ Enclosure ❑ Disposal only ❑ Cleanup 7 Other, specify: ❑ Full containment 12 Is the job being conducted: (] Indoors? ❑Outdoors? b.Asbestos Analytical Lab DOS Certification Number 2/23/2011 b.E nd Date(mml ddl yyyy) N/A d.Work hours Sal- un. b-Describe b.Describe • anf001ap.doc•10/02 Asbestos Notification Form•Page 1 of 3 14. Describe the decontamination system(s)to be used: SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NE(4 0 B. Facility Description o 1 Current or prior use of facility 0 2 Is the facility owner-occupied residential with 4 units or less? Yes Commonwealth of Massachusetts Asbestos Notification Form ANF-001 ■ 100120346 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed,enclosed,or encapsulated: 0 a.Total pipes or ducts(linear ft) c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing I.Cloths,woven fabrics A Thermal,solid core pipe insulation b. total other surfaces(square ft) S9_ft Lin.ft. Sq.ft. Lin.ft Lin.ft Sq ft d Insulating cement f.Trowel/Sprayer coatings h.Transite board,wall board j.Other,please specify. (VAT ft. Lin.R. Lin.ft. Sq ft. Lin,ft. Sq.ft Sq 4 SQ ft. ( Lin.ft. Sq.ft. I.Specify 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY&DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: (N/A b.Title IN/A d.DEP Waiver if N/A 0 H¢ml Title IN/A h.DOS Waiver if N/A a.Name of DEP Officio c.Date(mm/dd/yyyy)of Authorization N/A e.Name of DOS Officio g.Date(mm/dd/yyyy)of Authorization 17 Do prevailing wage rates as per M.G.L.c 49,§26,27 or 27A—F apply to this project? Yes l No RESIDENTIAL 3. 0 0 IL z IQ NORTHAMPTON HOUSING AUTHORITY a. Facility Owner Name [NORTHAMPTON c.City/Town JOHN CONNERS 4' a.Name of Facility Owner's On Site Manager J 01060 d.Zip Code • anfootap.doc•10/02 WARWICK c.city/-own J 02886 d.Zip Code 12 No 49 OLD SOUTH STREET b.Address 1413-584-4030 e.Telephone Number(area code and extension) 3600 WEST SHORE DRIVE b On-Site Manager Address 1 (401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form•Page 2 of 3■ pie:Transfer rations must mply with the lid Waste vision :gulations 310 OR 19 000 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 [100120346 Decal Number B. Facility Description (cont.) NATIONAL REFRIGERATION a.Name of General Contractor WARWICK c.Ciryfrown 102886 d Zip Code AIG f.Contractor's Worker's Comp.Insurer 6. What is the size of this facility? 3600 WEST SHORE DRIVE b.Address 401-737.2000 e.Telephone Number(area code and extension) IWC5318622 q.Policy Number 11/4/2011 h.Exp.Date(mm/dd/vny) a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site (if necessary): ACCUTECH INSULATION&CONTRACTING, II a.Name of Transporter LUDLOW c.City/Town 01056 d.Zip Code 100 STATE ST. BLDG 119, PO BOX 376 b Address 4135835500 e.Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: RED TECHNOLOGIES a.Name of Transporter BLOOMFIELD c.Ditv/fown 3. I 06002 d Zip Code a.Refuse Transfer Station and Owner c City/Town d.Zip Code 10 NORTHWOOD DRIVE b Address 8602182428 e.Telephone Number b.Address MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 1000 MINERVA ROAD c.Final Disposal Site Address 1OH e.State 144688 1 1 f Zip Code 0 • D. Certification ce The undersigned hereby states,under the o penalties of perjury,that he/she has read the io Commonwealth of Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information contained in this notification is true and correct ° to the best of his/her knowledge and belief. IL 2 C anf001ap doc•10/02 e.Telephone Number b.Final Disposal Site Location Owners Name WAYNESBURG d.City/Town g.Telephone Number (FAITH LEMAY a.Name IADMIN ASSIST Position/Title 14135835500 inefiraikai v ITH LEMA i J Authorized Signature 2/4/2011 mo�d--Date(mm/ddlvyyv) �ACCUTECH INSULATION e.Telephone Number L Representing 1100 STATE ST. BLDG 119, PO BOX 376 q Address [LUDLOW h City/Town 01056 Zip Code Asbestos Notification Form•Page 3 of 3 II 'HAMPSHIRE HEIGHTS a.Name of Facility !Northampton c.City/Town 1 Commonwealth of Massachusetts IL Asbestos Notification Form ANF-001 atant. ,fining out s on the toter,use the tab key ve your -do not the return rRUCTIONS 1100120354 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? SI Yes ❑No b.Provide blanket decal number if applicable: 2. Facility Location: 11 sections of this 1 must be 1pleted in order omply with notification arements of 310 R 7.15 I the Division )ccupational "ety(DOS) iuiretre en of 453 IR 612 J !MA d Slate 3. Worksite Location: 'HAMPSHIRE HEIGHTS 1 (BLDG 15 a Building Name/Building Location b.Building N 4. Is the facility occupied? al Yes ❑No 5. Asbestos Contractor: ks CUTECH INSULATION &CONTRACTING I] a Name LUDLOW 101056 c.City/Town _-_—,-- d.z_ Code IAC000005 __ -J f.DOS License Number JON HITE h.Facility Contact Person 'JULIO VENTURA -_ 6' a.Name of On-Site Sup n sor/Foreman 7 1N/A a.Name of Project Monitor 8 (N/A -_ a Name of Asbestos Analytical Lab 12/23/2011 a Project Start Date(mmlddtyyyy)__ o I7AM-4PM c.Work hours Mon-Fri. o 10. a. What type of project is this? o ❑ Demolition El Renovation ❑ Repair ❑ Other, please specify: 11. a. Check abatement p ocedures: 0 Glove bag ❑Encapsulation ❑Enclosure ❑ Disposal only ❑ Cleanup ❑Other,specify: ❑ Full containment z Blanket Decal Number 110 JACKSON STREET b.Street Address 01060 a.Zip Code 1 c.Wing (4015692277 I.Telephone Number PST FLOOR d.Floor 'APT'S A& D ' e.Roam 1100 STATE STREET b.Address 4135835500 e.Telephone Number g. Contract Type: 0 Written ❑Verbal I.Contact Person's Title 'AS001178 b.Supervisor/Foreman DOS Certification Number IN/A b.Project Monitor DOS Certification Number 'N/A b.Asbestos Analytical Lab DOS Certification Number__ 12/2312011 b E nd Date(mm1 m/yyyy) --I d.Work hours Sat-Sun. 1 IN/A b.Describe b.Describe 12. Is the job being conducted: WI Indoors? ❑Outdoors? an1001ap.doc•10/02 Asbestos Notification Form•Page 1 of 3 U SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH 8 REMOVE USING THE NEG Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120354 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or encapsulated: 0 a.Total pipes or ducts(linear ft) c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g-Spray-on fireproofing i.Cloths,woven fabrics k.Thelma!,solid core pipe insulation 4 h.Total other surfaces(square ft) ( Lin.ft. 14. Describe the decontamination system(s)to be used: d Insulating cement L Trowel/Sprayer coatings h.Transite board,wall board J.Other,please specify: Lin.ft. Lin.ft. Lin.ft. Lin.ft J Sq ft Sq ft VAT L specify 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY 8 DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: N/A a.Name of DEP Official c.Date(mm/dd/yyyy)of Authorization N/A e.Name of DOS Official J g.Date(mm/dd/yyyy)of Authorization N/A b.Title N/A d DEP Waiver# N/A f DOS Official Title N/A h.DOS Waiver# 17. Do prevailing wage rates as per M.G.L. c. 149, §26,27 or 27A—F apply to this project? Yes El Na B. Facility Description 1 Cu torp .0 us ff cirty' (RESIDENTIAL 2 Is the facility owner-occupied residential with 4 units or less? 3 a.Facility Owner Name NORTHAMPTON HOUSING AUTHORITY o NORTHAMPTON o c.City/Town 4 JOHN CONNERS a Name of Facility Owner's On-Site Manager Z 01060 ❑Yes 17 No 49 OLD SOUTH STREET b.Address 413-584.4030 d.Zip Code WARWICK C c City/Town anf001ap dos 10/02 02886 d.Zip Code e.Telephone Number(area code and extension) 3600 WEST SHORE DRIVE b.On-Site Manager Address 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form•Page 2 of 3 • ACCUTECH INSULATION CONTRACTING, II Commonwealth of Massachusetts �. � Asbestos Notification Form ANF-001 Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19.000 [100120354 Decal Number B. Facility Description (cont.) 5' a.Name of General Contractor NATIONAL REFRIGERATION WARWICK C.City/Town 02886 d Zip Code AIG Contractors Workers Comp.Insurer 6. What is the size of this facility? 3600 WEST SHORE DRIVE b.Address 401-737-2000 e.Telephone Number(area code and extension) WC5318622 q.Policy Number 11/4/2011 h Exp Date(mm/dd/yyyy) a.Square Feet b Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site Of necessary): a.Name of Transporter LUDLOW c.City/Town 01056 d Zip Code 100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 e.Telephone Number Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: RED TECHNOLOGIES a.Name of Transporter BLOOMFIELD c.City/Town 10 NORTHWOOD DRIVE 06002 d.Zip Code a.Refuse Transfer Station and Owner c.Gity/Town MINERVA ENTERPRISES INC b.Address 8602182428 e.Telephone Number b Address d.Zip Code a.Final Disposal Site Location Name 9000 MINERVA ROAD c.Final Disposal Site Address 'OH e.State 44688 f Zip Code e Telephone Number b Final Disposal Site Location Owners Name WAYNESBURG d City/rown g.Telephone Number D. Certification The undersigned hereby states,under the p If fp j ry,th th / h h dth C Ith fM h n g I for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15, and that the information t ed th' tf f ' t d t ° to the best of his/her knowledge and belief. 0 Z C • anf001ap doc•10/02 FAITH LEMAY a Name ADMIN ASSIST c Position/Title 4135835500 F•ITH LEMAY Authorized Signature 2/4/2011 d.Date(mm/dd/yyyyt ACCUTECH INSULATION e.Telephone Number f Representing 100 STATE ST. BLDG 119, PO BOX 376 q.Address 'LUDLOW h City/Town 01056 Zip Code Asbestos Notification Form•Page 3 of 3 II Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100120357 Decal Number A. Asbestos Abatement Description 1. a. Is this facility fee exempt-citvtown, district, municipal housing authority, owner-occupied residence of four units or less? LLJ Yes ❑No b. Provide blanket decal number if applicable: 2. Facility Location: HAMPSHIRE HEIGHTS a.Name of Facility Northampton a City/rown INSTRUCTIONS 3. Worksite Location: 1.All sections of this form must be completed in order to comply with 4 DEP notification requirements of 310 CMR].15 5 and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 6.12 HAMPSHIRE HEIGHTS a.Building Name/Building Location Is the facility occupied? Asbestos Contractor: t'/ MA d.State BLDG 16 b.Building# Yes ❑ No ACCUTECH INSULATION &CONTRACTING I a.Name LUDLOW c.City/Town AC000005 01056 d.Zip Code E DOS License Number Blanket Decal Number 10 JACKSON STREET b.Street Address 01060 e Zip Code c.Wing 4015692277 f Telephone Number 1ST FLOOR d Floor APT'S A& D e Room 100 STATE STREET b.Address 4135835500 e.Telephone Number g. Contract Type: Written LI Verbal JON HITE h.Facility Contact Person JULIO VENTURA 6. a Name of On-Site Supervisor/Foreman N/A 7. a.Name of Project Monitor N/A 8- a.Name of Asbestos Analytical Lab 9 a Project Start Date(mm/dd/yyyy) 2/24/2011 7AM-4PM c.Work hours Mon-Fn. 10 a What type of project is this? I� Demolition ❑ Renovation ❑ Repair ❑ Other, please specify: 11. a. Check abatement procedures: o Glove bag ❑ Encapsulation o ❑ Enclosure ■ Disposal only ❑Cleanup ❑ Other, specify: ❑ Full containment ra Z i.Contact Person's Title AS001178 L Supervisor/Foreman DOS Certification Number N/A b.Project Monitor DOS Certification Number N/A b.Asbestos Analytical Lab DOS Certification Number 2/24/2011 b.E nd Date(mot/dd/yyyy) N/A d.Work hours Sat-Sun. b. Describe b.Describe 12. Is the job being conducted: LAA Indoors? ❑Outdoors? anfoolap doc•10/02 Asbestos Notification Form•Page 1 of 3• I Commonwealth of Massachusetts IAsbestos Notification Form ANF-001 LI 0 N O O LL 2 • 100120357 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed, or encapsulated: 0 a.Total pipes or ducts(linear ft) c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing i.Cloths,woven fabrics k.Thermal,solid core pipe insulation 4 b. I otal other s Waces(square n) Lin.ft. Lin ft Lin.ft Lin.ft. Lin.ft. Sq.ft. Sq ft. Sq ft d.Insulating cement f.Trowel/Sprayer coatings h.Transite board wall board S X I.Other,please specify: VAT Sq.ft, I.Specify Lin.ft Lin.ft Lin ft. Lin.ft. Sq.ft. S J q ft�.___j1 J 4 Sq.ft 14. Describe the decontamination system(s)to be used: SEAL CRITICALS WI 6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH E. REMOVE USING THE NEI 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY 8 DELIVERED IN A SEALED VEHICL I 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: N/A a.Name of DEP Official N/A b.Title N/A c.Date(mm/dd/yyyy)of Authorization d.DEP Waiver p N/A N/A a.Name of DOS Official L DOS Official Title g.Date(mm/dd/yyyy)of Authorization N/A h.DOS Waiver ft 17 Do prevailing wage rates as per M.G.L.c. 149, §26, 27 or 27A-F apply to this project? Z Yes❑No B. Facility Description 1 Cu re t o p .0 use of facility: RESIDENTIAL 2. Is the facility owner-occupied residential with 4 units or less? ❑Yes fl No 3. 4. NORTHAMPTON HOUSING AUTHORITY a.Facility Owner Name NORTHAMPTON c.City/Town 01060 d Zip Code JOHN CONNERS a.Name of Facility Owner's On-Site Manager WARWICK anf001ap.doc•10/02 c.City/Town 02886 49 OLD SOUTH STREET b.Address 413-584-4030 1 a.Telephone Number(area code and extension) 3600 WEST SHORE DRIVE b.On-Site Manager Address 401-569-2277 d.Zip Code e.Telephone Number(area code and extension) Asbestos Notification Form-Page 2 of 3 Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19.000 ° Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100120357 Decal Number B. Facility Description (cont.) 5' a.Name of General Contractor NATIONAL REFRIGERATION WARWICK c.City/Town 02886 d.Zip Code AIG f.Contractors Worker's Comp.Insurer 6. What is the size of this facility? 3600 WEST SHORE DRIVE b.Address 401-737-2000 e.Telephone Number(area code and extension) J WC 5318622 g.Policy Number a_Square Feet 11/412011 h.Exp.Date(mm/dd/yyyy) b.Number of floors C. Asbestos Transportation and Disposal Transporter of asbestos-containing material from site to temporary storage site Of necessary): ACCUTECH INSULATION &CONTRACTING, I a.Name of Transporter LUDLOW c.City/Town 01056 d.Zip Code 100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 e.Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: RED TECHNOLOGIES a.Name of Transporter BLOOMFIELD c.City/Town 06002 d Zip Code 10 NORTHWOOD DRIVE b.Address 8602182428 e Telephone Number r a.Refuse Transfer Station and Owner r b.Address d.Zip Code c City/Town MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 9000 MINERVA ROAD c.Final Disposal Site Address OH e.State e Telephone Number 44688 f Zip Code b.Final Disposal Site Location Owner WAYNESBURG d.City/Town Name g Telephone Number D. Certification The undersigned hereby states,under the p It' fp rj ry,th th / h h dth C Ith f M h tt g I f for the Removal,Containment or E cap I t. f Asb t 453 CMR 6.00 and 310 CMR 7.15,and that the information t ' d th' tic t' t d [ ° to the best of his/her knowledge and belief. 0 z a 111 anf001ap.doc 10/02 FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 4135835500 e.Telephone Number d.Date(mm/dd/wwl ACCUTECH INSULATION f.Representing 100 STATE ST. BLDG 119, PO BOX 376 g Address LUDLOW h.City/Town 01056 Zip Code Asbestos Notification Form•Page 3 of 3 El Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. INSTRUCTIONS Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100120358 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: HAMPSHIRE HEIGHTS a.Name of Facility Northampton c.City/Town 3. Worksite Location: 1.All sections of firs form must be completed in order to comply with 4 DEP notification requirements of 310 CMR 715 5 and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 6.12 6. 7. 8. 0 9 0 HAMPSHIRE HEIGHTS a.Building Name/Building Location Is the facility occupied? Asbestos Contractor: MA d.State BLDG 17 b.Building p Yes ❑No ACCUTECH INSULATION &CONTRACTING I a Name LUDLOW c.City/Town AC000005 01056 d Zip Code L DOS License Number Blanket Decal Number 10 JACKSON STREET b.Street Address 01060 e.Zip Code c.Wing 4015692277 L Telephone Number 1ST FLOOR d.Floor APT'S A&D e.Room 100 STATE STREET b.Address 4135835500 e.Telephone Number g. Contract Type: [✓] Written ❑Verbal JON HITE h.Facility Contact Person (JULIO VENTURA a.Name of On-Site Supervisor/Foreman J N/A a.Name of Project Monitor N/A a.Name of Asbestos Analytical Lab 2/24/2011 c.Work hours Mon-Fri. 10 a What type of project is this? ❑ Demolition al Renovation ❑ Repair ❑ Other, please specify: 11. a. Check abatement procedures: Glove bag o ❑ Enclosure ❑Cleanup ❑ Full containment Z 12. Is the job being conducted: U anf001ap doc•10/02 ❑ Encapsulation ❑ Disposal only ❑ Other, specify: Indoors? Contact Person's Title AS001178 b.Supervisor/Foreman DOS Certification Number N/A b.Project Monitor DOS Certification Number N/A b.Asbestos Analytical Lab DOS Certification Number 2/24/2011 b.E nd Date(mml dell yyyy) N/A d.Wark hours Sat-Sun. b.Describe b.Describe Outdoors? Asbestos Notification Form•Page 1 of 3 ISEAL CRITICALS W/6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NEG Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120358 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or encapsulated: 0 a.Total pipes or ducts(linear ft) c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing i.Cloths,woven fabrics k.Thermal,solid core pipe insulation 4 b.Total other surfaces(square ft) Lin.ft Lin.ft. Lin ft. Lin.ft. Lin ft. Sq.ft. Sq.ft Sq.ft. S ft. Sq.ft. 14. Describe the decontamination system(s)to be used d.Insulating cement f.Trowel/Sprayer coatings h.Transite board,wall board j.Other,please specify: Lin.ft Lin.ft. Sq.ft. Lin Lin.ft. 4 Sq.ft. VAT I.Specify 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY& DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: N/A a.Name of DEP Official c.Date(mm/dd/yyyy)of Authorization N/A e.Name of DOS Official N/A b.Title N/A d.DEP Waiver p N/A DOS Official Title N/A I g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver# 17. Do prevailing wage rates as per M.G.L. C. 149, §26,27 or 27A—F apply to this project? n Yes❑No B. Facility Description 1 Current or prior use of facility: RESIDENTIAL 2 Is the facility owner-occupied residential with 4 units or less? 3 0 0 LL 4 z NORTHAMPTON HOUSING AUTHORITY a.Facility Owner Name NORTHAMPTON c.City/Town JOHN CONNERS a.Name of Facility Owners On-Site Manager j 01060 d.Zip Code WARWICK anf001ap doc•10/02 C.CM/Town 02886 d Zip Code 1 ❑Yes No 49 OLD SOUTH STREET b.Address 413-584-4030 e.Telephone Number(area code and extension) 3600 WEST SHORE DRIVE b.On-Site Manager Address 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form•Page 2 of 3 Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19.000 0 0 0 0 IL Z Commonwealth of Massachusetts Asbestos Notification Form ANF-001 00120358 Decal Number B. Facility Description (cont.) 5 NATIONAL REFRIGERATION a.Name of General Contractor WARWICK c.City/Town 02886 d.Zip Code AIG f.Contractors Worker's Camp.Insurer 6. What is the size of this facility? 3600 WEST SHORE DRIVE b.Address 1401-737-2000 e.Telephone Number(area cod and extension) WC 5318622 q.Policy Number a.Square Feet 11/4/2011 h.Exp.Date(mmldd/yyyy) b.Number of Doors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): ACCUTECH INSULATION &CONTRACTING, I a.Name of Transporter LUDLOW c.City/Town 01056 d.Zip Cade 100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 e.Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 3 RED TECHNOLOGIES a.Name of Transporter BLOOMFIELD C.City/Town 06002 d.Zip Code 10 NORTHWOOD DRIVE b.Address a.Refuse Transfer Station and Owner C.City/Town d Zip Code MINERVA ENTERPRISES INC a Final Disposal Site Location Name 9000 MINERVA ROAD c.Final Disposal Site Address OH e.State 602182428 e.Telephone Number b.Address e.Telephone Number b. Final Disposal Site Location Owner's Name WAYNESBURG 44688 f Zip Code d.City/Town g.Telephone Number D. Certification The undersigned hereby states,under the penalties of perjury,that he/she has read the Commonwealth of Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15, and that the information ntained in this notification is true and correct to the best of his/her knowledge and belief. anf001ap.doc•10/02 FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 4135835500 Tele hone Number A /r ' I ho LEMA Authorized Signature 2/4/2011 d.Date(mm/ddlvvvv) 0 ACCUTECH INSULATION f.Re,resentin 100 STATE ST. BLDG 119, PO BOX 376 p.Address LUDLOW h.City/Town 01056 i Zip Code Asbestos Notification Form•Page 3 of 3 I♦ Important: When filling out forms on the computer.use only the tab key to move your cursor-do not use the return key Commonwealth of Massachusetts Asbestos Notification Form ANF-001 ■ 100120362 Decal Number A. Asbestos Abatement Description a. Is this facility fee exempt-citvtown,district, municipal housing authority, owner-occupied residence of four units or less? i!J Yes ❑No b.Provide blanket decal number if applicable: INSTRUCTIONS Facility Location: HAMPSHIRE HEIGHTS a-Name of Facility Northampton c.City/Town 3. Worksite Location: 1.All sections of this form must be completed in order to comply with 4. DEP notification requirements of 310 CMR7.15 5. and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 6.12 HAMPSHIRE HEIGHTS a.Building Name/Building Location Is the facility occupied? Asbestos Contractor: MA d.State BLDG 18 b Building p Yes ❑No ACCUTECH INSULATION 8 CONTRACTING I a.Name LUDLOW c City/Town AC000005 01056 d Zip Code f.DOS License Number JON HITE h.Facility Contact Person Blanket Decal Number 10 JACKSON STREET b.Street Address 01060 JULIO VENTURA 6' a.Name of On-Site SupervisoriForema N/A 7- a.Name of Project Monitor N/A 6. a.Name of Asbestos Analytical Lab 9 2/25/2011 o a.Project Start Date(mmldd/yyyy) O 7AM-4PM c Work hours Mon-Fri. o 10 a What type of project is this? 0 Z ❑ Demolition ❑ Repair Renovation p Other, please specify: 11. a Check abatement procedures: Glove bag ❑ Enclosure ❑ Cleanup ❑ Full containment ❑ Encapsulation ❑ Disposal only ❑ Other, specify: e.Zip Code E Wing 4015692277 f.Telephone Number 1ST FLOOR d.Floor APT'S A 8 D e.Room [100 STATE STREET b.Address 4135835500 e.Telephone Number g. Contract Type: 0 Written ❑Verbal i.Contact Person's Title LAS001178 b.Supervisor/Foreman DOS Certification Number N/A b.Project Monitor DOS Certification Number N/A b.Asbestos Analytical Lab DOS Certification Number 12/25/2011 b E d Date(mm/dd/yyyy) LNIA d.Work hours Sat-Sun. b. Describe b.Describe • 12. Is the job being conducted: 4 Indoors? ❑Outdoors? anf001ap dec•10/02 Asbestos Notification Form•Page I of 3 II Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120362 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or encapsulated: 0 a.Total pipes or ducts(linear ft) c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g Spray-on fireproofing Cloths,woven fabrics k.Thermal,solid care pipe insulation 4 b.Total other surfaces(square ft) Lin.ft Lin ft. Lin.ft. Sq.ft Lin.ft Lin.fl. Sq.ft. S .ft. d.Insulating cement f.Trowel/Sprayer coatings h.Transite board,wall board j.Other,please specify Lin.ft. Sq.ft. 4 Sq VAT Sq_9_ I.Specify 14. Describe the decontamination system(s)to be used SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NEC} 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY& DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: N/A a.Name of DEP Official c.Date(mMdd/yyyy)of Authorization N/A a.Name of DOS Official g.Date(mmlddlyyyy)of Authorization N/A b.Title N/A d.DEP Waiver a N/A t.DOS Official Title N/A h.DOS Waiver ft 17. Do prevailing wage rates as per M.G.L. c. 149,§26, 27 or 27A—F apply to this project? ❑Yes❑ No B. Facility Description N 0 1 Current or prior use of facility: 0 0 0 LL z RESIDENTIAL 2 Is the facility owner-occupied residential with 4 3 4" a.Name of Facility Owners On-Site Manager 02886 d Zip Code units or less? NORTHAMPTON HOUSING AUTHORITY a.Facility Owner Name NORTHAMPTON c.City/Town 1 01060 d.Zip Code Lives YANo JOHN CONNERS WARWICK anf001ap.doc•10/02 c.City/Town 49 OLD SOUTH STREET b Address 413-584-4030 e.Telephone Number(area code and extension) 3600 WEST SHORE DRIVE b.On-Site Manager Address 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form•Page 2 of 3 U Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19 000 m 0 O 0 LL Z C Commonwealth of Massachusetts Asbestos Notification Form ANF-001 [100120362 Decal Number B. Facility Description (cont.) 5 NATIONAL REFRIGERATION a.Name of General Contractor WARWICK c.City/Town 02886 d.Zip Code AIG f Contractors Worker's Comp.Insurer 6. What is the size of this facility? 3600 WEST SHORE DRIVE b.Address 401-737-2000 e.Telephone Number(area code and extension) WC5318622 q.Policy Number a.Square Feel 11/4/2011 h.Exp.Date(mm/dd/yyyy) b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site (if necessary): ACCUTECH INSULATION&CONTRACTING, I a.Name of Transporter LUDLOW c.City/Town 01056 d.Zip Code 2. Transporter of asbestos-containing waste material RED TECHNOLOGIES a.Name of Transporter BLOOMFIELD c.City/Town 06002 d.Zip Code a.Refuse Transfer Station and Owner c.City/Town J d.Zip Code MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 19000 MINERVA ROAD c.Final Disposal Site Address 100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 e.Telephone Number from removal/temporary site to final disposal site: 10 NORTHWOOD DRIVE b.Addre 8602182428 e.Telephone Number b Address e.Telephone Number OH e.State 44688 f.Zip Code b.Final Disposal Site Location Owners Name WAYNESBURG d.City/Town g.Telephone Number D. Certification The undersigned hereby states, under the penalties of perjury,that he/she has read the Co o ealth of Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information ontained in this notification is true and correct to the best of his/her knowledge and belief. anfoolap doc-10/02 FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 4135835500 e.Tele hone Number 00 STATE ST. BLDG 119, q Address LUDLOW h.City/Town .Authorized Signature 2/4/2011 d. Date(mm/dd/vwv) PO BOX 376 376 ACCUTECH INSULATION' CRnq� 01056 i.Zip Code Asbestos Notification Form-Page 3 of 3 U Important: Nhen filling out 'arms on the computer,use only the tab key :o move your zursor-do not /se the return Key. INSTRUCTIONS Commonwealth of Massachusetts Asbestos Notification Form ANF-001 00120364 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? 17 Yes ❑No b.Provide blanket decal number if applicable: 2. Facility Location: HAMPSHIRE HEIGHTS a.Name of Facility Northampton a City/Town 3. Worksite Location: 1.All sections of this lorm must be completed in order to comply with 4. DEP notification requirements of 310 CMR]15 5. and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 6.12 6. a.Name of On-Site Supervisor/Foreman HAMPSHIRE HEIGHTS a.Building Name/Building Location Is the facility occupied? Asbestos Contractor: IA MA d State BLDG 19 b.Building# Yes ❑No Blanket Decal Number 10 JACKSON STREET b Street Address 01060 e.Zip Code [ACCUTECH INSULATION &CONTRACTING I a.Name LUDLOW c.City/Town AC000005 L DOS License Number 01056 d.Zip Code 1 JON HITE h.Facility Contact Person JULIO VENTURA N/A 7' a.Name of Project Monitor 8 0 9 0 N 0 0 o a Glove bag o ❑ Enclosure ❑Cleanup ❑ Full containment 12. Is the job being conducted N/A a.Name of Asbestos Analytical Lab 2/25/2011 a.Project Start Date(mmldd!nn) 7AM-4PM c Wing 4015692277 f Telephone Number 1ST FLOOR d Floor APT'S A& F e.Room 100 STATE STREET b.Address 4135835500 e.Telephone Number g.Contract Type: 'A Written ❑Verbal i.Contact Person's Title AS001178 b.Supervisor/Foreman DOS Certification Number N/A b.Project Monitor DOS Certification Number N/A b.Asbestos Analytical Lab DOS Certification Number 2/25/2011 b.E nd Date(mml ddl yyyy) c.Work hours Mon-Fn. 10 a What type of project is this? 11 ❑ Demolition ❑ Repair 17 Renovation ❑Other, please specify: a. Check abatement procedures: Z anfoOlap.doc•10/02 ❑ Encapsulation ❑Disposal only ❑Other,specify: N/A d Work hours Sat-Sun. b.Describe 0.Describe [ Indoors? ❑Outdoors? Asbestos Notification Form•Page 1 of 3 U SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NEG LiCommonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120364 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or encapsulated: 0 a.Total pipes or ducts(linear ft) c.Boiler,breathing,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing i.Cloths,woven fabrics k.Thermal,solid core pipe insulation b.Total other surfaces(square ft) L in.ft L in.ft Lin.ft. L in.ft. Lin.ft. Sq ft Sq.ft. Sq.ft. d.Insulating cement f.Trowel/Sprayer coatings h.Transite board,wall board S tt l j.Other,please specify: VAT sq.ft. I.Specify 14. Describe the decontamination system(s)to be used: Lin.ft. Sq.ft. Lin.ft. Sq.tt. 1tt -J 4 Lin.f. Sq.tt. 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY&DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: N/A a.Name of DEP Official c.Date(mm/dd/yyyy)of Authonzation N/A e.Name of DOS Official g.Date(mm/dd/yyyy)of Authorization N/A b.Title N/A d.DEP Waiver k N/A f.DOS Official Title N/A h.DOS Waiver g 17. Do prevailing wage rates as per M.G.L.c. 149, §26, 27 or 27A—F apply to this project? Yes[I No ° B. Facility Description 0 d z C 1 Current or prior use of facility: (RESIDENTIAL 2 Is the facility owner-occupied residential with 4 units or less? 3 NORTHAMPTON HOUSING AUTHORITY a.Facility Owner Name NORTHAMPTON c.City/Town _J 01060 d.Zip Code JOHN CONNERS 4. a.Name of Facility Owner's On-Site Manag r J WARWICK anf001ap doc•10/02 c.City/Town 02886 d Zip Code ❑Yes GI No 49 OLD SOUTH STREET b.Address 413-584-4030 e.Telephone Number(area code and extension) 3600 WEST SHORE DRIVE b.On-Site Manager Address 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form Page 2 of 3 VI 0 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19.000 `100120364 Decal Number B. Facility Description (cont.) 5. NATIONAL REFRIGERATION a.Name of General Contractor WARWICK C.clty/rown AIG f.Contractor's Worker's Comp.Insurer 6. What is the size of this facility? 02886 d.Zip Code 3600 WEST SHORE DRIVE b.Address 401-737-2000 e Telephone Number(area cod and extension) WC5318622 Ip.Policy Number a.Square Feet 11/4/2011 h.Exp.Date(mm/dd/yyyy) b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site ACCUTECH INSULATION S CONTRACTING, I N fT LUDLOW c.City/Town 01056 necessary): 100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 d.Zip Code e.Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 3 RED TECHNOLOGIES a.Name of Transporter BLOOMFIELD c.City/Town 06002 d.Zip Code 10 NORTHWOOD DRIVE b.Address 8602182428 e Telephone Number a.Refuse Transfer Station and Owner c.City/Town 4. !MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 0_000 MINERVA ROAD c Flnal Disposal Site Address OH e.State d.Zip Code b Address 44688 L Zip Code e Telephone Number b.Final Disposal Site Location Owner's Name WAYNESBURG d.Ciy/rown g.Telephone Number ° D. Certification The undersigned hereby states,under the o penalties of perjury,that he/she has read the o Co monwealth of Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,453 CMR 600 and 310 CMR 7.15, and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. 0 u Z C anf001ap.doc 10102 FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 4135835500 e.Telephone Number Wei- 7H LEMAY I dr Authorized Signature 2/4/2011 d Date(mm/dd/ww) ACCUTECH INSULATION f.Representing 100 STATE ST. BLDG 119, PO BOX 376 q.Address LUDLOW h City/Town 01056 i.Zip Code Asbestos Notification Form•Page 3 of 3 El mportanL Vhen filling out orms on the :omputer,use rnly the tab key o move your :ursor-do not rse the return cey. INSTRUCTIONS Commonwealth of Massachusetts Asbestos Notification Form ANF-001 ■ 100120118 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? 4 Yes ❑No b. Provide blanket decal number if applicable: 2. Facility Location: HAMPSHIRE HEIGHTS a Name of Facility Northampton c.City/Town 3. Worksite Location: 1.All sections of this form must be completed in order to comply with 4 DEP notification requirements of 310 5 CMR 7.15 and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 612 6. 7. 8. 9 0 0 10 0 HAMPSHIRE HEIGHTS 0 a-Building Name/Building Location Is the facility occupied? Asbestos Contractor: 0 IMA d.State BLDG 1 b.Building# Yes ❑No ACCUTECH INSULATION &CONTRACTING I a Name LUDLOW c.City/Town IAC000005 f.DOS License Number 01056 d.Zip node JON HITE h.Facility Contact Person 'JULIO VENTURA a.Name of On-Site Supervisor/Foreman 1N/A a.Name of Project Monitor N/A a.Name of Asbestos Analytical Lab 12/17/2011 a.Project Start Date(mmlddlyyyy) 7AM-4PM c.Work hours Mon-Fri. a What type of project is this? ❑Demolition ❑ Repair a Renovation ❑ Other, please specify: 11. a. Check abatement p ocedures: _ Glove bag ❑ Encapsulation ❑ Enclosure ❑Disposal only ❑ Cleanup ❑Other,specify: LL ❑ Full containment 12. Is the job being conducted: [JJ Indoors? ❑Outdoors? Z C Blanket Decal Number 10 JACKSON STREET b Street Address 01060 e.Zip Code r c.Wing 4015692277 f Telephone Number 1ST FLOOR d Floor APT'S A& D e.Room 100 STATE STREET b.Address 4135835500 e.Telephone Number g. Contract Type: F' Written ❑Verbal I.Contact Person's Title AS001178 b Supervisor/Foreman DOS Certification Number N/A b.Project Monitor DOS Certification Number N/A b.Asbestos Analytical Lab DOS Certification Number [2/17/2011 b E nd Date(mm/dd/yyyy) 'N/A d.Work hours Sat-Sun. b.Describe b Describe anf001apdoc•10/02 Asbestos Notification Form•Page 1 of 3 14. Describe the decontamination system(s)to be used: SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH 8 REMOVE USING THE NEf.# Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120118 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or encapsulated: 0 a.Total pipes or ducts(linear ft) c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing Cloths,woven fabrics k.Thermal,solid core pipe insulation 4 b. Total other surf aces(square ft) Lin ft. Lin.ft. Lin ft. Sq.ft. Lin ft Sq.ft. Sq.ft. Lin.ft. S .ft. VAT Sq ft. I.Specify d.Insulating cement f.Trowel/Sprayer coatings h.Transite board,wall board j.Other,please specify: Lin.0. Sq ft. Lin.ft. Sq.ft. _J q. t. Lin.ft. Li 4 Sq 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY 8 DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: N/A a.Name of DEP Official N/A b Title c.Date(mn'dd/yyyy)of Auth izati N/A e.Name of DOS Official g.Date(mmfdd/yyyy)of Authorization 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? N/A d DEP Waiver# N/A f.DOS Official Title IN/A h.DOS Waiver if i7 Yes❑No B. Facility Description 0 1 Current or prior use of facility: 0 3 a Facility Owner Name "RESIDENTIAL Is the facility owner-occupied residential with 4 units or less? _;Yes No (NORTHAMPTON HOUSING AUTHORITY 4 (NORTHAMPTON c.cityrrown J 101060 d.Zi p Code JOHN CONNERS a Name of Facility Owner's On-Site Manager 02886 Z "WARWICK c.CityfTown anmotap.doc 10102 d.Zip Code 49 OLD SOUTH STREET b.Address 1 1413-584-4030 e Telephone Number(area code and extension) 13600 WEST SHORE DRIVE b.On-Site Manager Address 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form Page 2 of 3 Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19 000 0 cv 0 0 0 LL 2 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100120118 Decal Number B. Facility Description (cont.) NATIONAL REFRIGERATION a.Name of General Contractor WARWICK c.City/Town 02886 d.Zip Code AIG f.Contractors Worker's Comp.Insurer 6. What is the size of this facility? 3600 WEST SHORE ROAD b.Address 401-737-2000 e.Telephone Number(area code and extension) WC5318622 y.Policy Number a.Square Feet J 1/4/2011 h.Exp.Date(mmldd/WW) b Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site (if necessary): ACCUTECH INSULATION &CONTRACTING, II a.Name of Transporter LUDLOW 01056 c.City/Town d.Zip Code 100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 e Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: RED TECHNOLOGIES a.Name of Transporter BLOOMFIELD c.City/Town 06002 d.Zip Code 10 NORTHWOOD DRIVE b Address 8602182428 e.Telephone Number a.Refuse Transfer Station and Owner c City/Town d.Zip Code MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 19000 MINERVA ROAD C.Final Disposal Site Address OH e.State b.Address e.Telephone Number 44688 f.Zip Code D. Certification The undersigned hereby states,under the penalties of perjury,that he/she has read the Commonwealth of Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. anfo0lapdoc•10/02 b.Final Disposal Site Locatio Owner's Name WAYNESBURG d Gay/Town g Telephone Number FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 4135835500 e.Telephone Number 100 STATE ST. BLDG 119, q.Address 1 1 LUDLOW h.City/Town th LeMay b.Authorized Signature 2/3/2011 d Date(mmldd/wry) ACCUTECH INSULATION! f. Representing PO BOX 376 01056 i Zip Code Asbestos Notification Form•Page 3 of 3 El l Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. INSTRUCTIONS Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120273 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? GI Yes ❑No b. Provide blanket decal number if applicable: 2. Facility Location: 3 1.All sections of this form must be completed in order to comply with 4 DEP notification requirements of 310 5 CMR 7.15 and the Division of Occupational Safely(DOS) notification requirements of 453 CMR 6.12 6. 7. 8. O 9. 0 'HAMPSHIRE HEIGHTS a Name of Facility NORTHAMPTON c.Cityrrown Worksite Location: 'HAMPSHIRE HEIGHTS a.Building Name/Building Location Is the facility occupied? Asbestos Contractor: • MA d State rBLDG 2 b.Building# Yes ❑ No Blanket Decal Number 10 JACKSON STREET b.Street Address 01060 e.Zip Code ACCUTECH INSULATION &CONTRACTING I a.Name LUDLOW c.City/Town AC000005 I.DOS License Number 01056 d.Zip Code JON HITE h.Facility Contact Person c.Wing 4015692277 f.Telephone Number 1ST FLOOR d Floor APT'S A&F e.Room 100 STATE STREET b.Address 4135835500 e.Telephone Number g. Contract Type: GI Written ❑Verbal JULIO VENTURA a.Name of On-Site Supervisor/Foreman N/A a.Name of Project Monitor Contac Per on's The AS001178 b.Supervisor/Foreman DOS Certification Number N/A N/A a.Name of Asbestos Analytical Lab 2/17/2011 a.Project Start Date(mm/dd/yyyy) 7AM-4PM c.Work hours Mon-Fri. b.Project Monitor DOS Certification Number N/A O 10 a What type of project is this? O ❑ Demolition t7 Renovation ❑ Repair ❑Other, please specify: 0 0 LL Z 11. a. Check abatement procedures: a Glove bag ❑ Enclosure ❑Cleanup ❑ Full containment 12. Is the job being conducted. C ❑ Encapsulation ❑Disposal only ❑Other, specify: anfo0lap.doc•10/02 b Asbestos Analytical Lab DOS Certification Number 2/17/2011 b.E nd Date(mm/dd/yyyy) N/A d.Work hours Sat-Sun. b.Describe b.Describe Indoors? I I Outdoors? Asbestos Notification Form•Page 1 of 3 IN/A a Name of DEP Official c.Date(mm/rid/yyyy)of Authorization 1N/A e.Name of DOS Official 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): (ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY& DELIVERED IN A SEALED VEHICLI 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: IN/A b.Title IN/A d.DEP Waiver# 0 0 0 LL 0 2 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 1100120273 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or encapsulated- a.Total pipes or ducts(linear ft) c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing i.Cloths,woven fabrics k.Thermal,solid core pipe insulation b.Total other surfaces(square ft) Lin.ft. Lin.ft. Sq.ft Sq.ft. Lin.ft. Sq.ft. Lin.ft. Lin.ft. d.Insulating cement f.Trowel/Sprayer coatings h.Transite board,wall board j.Other,please specify: [VAT Sq.ft. I.Specify 14. Describe the decontamination system(s)to be used: !SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH&REMOVE USING THE NE4i Lin.It. Lin.ft. Lin.ft. Sq.ft Sq.ft. Lin.fl. Sq_ft. I (NIA f DOS Official Title g.Date(mm/dd/yyyy)of Authorization 17. Do prevailing wage rates as per M.G.L.c. 149, §26, 27 or 27A—F apply to this project? B. Facility Description h DOS Waiver# (RESIDENTIAL 1 Current or prior use of facility: 2 Is the facility owner-occupied residential with 4 units or less? ❑Yes 149 OLD SOUTH STREET NORTHAMPTON HOUSING AUTHORITY 1 3. Ia.Facility Owner Name INORTHAMPTON C.City/Town (JOHN CONNERS 4' a.Name of Facility Owner's On-Site Manager 1WARWICK c.City/Town 101060 d Zip Code anf001ap doc•10/02 102886 d Zip Code Yes El No 0 No S Address 1413-584-4030 e.Telephone Number(area code and extension) 13600 WEST SHORE DRIVE b.On-Site Manager Address 1401-737-2000 a.Telephone Number(area code and extension) Asbestos Notification Form•Page 2 of 3 II Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19.000 ,n Commonwealth of Massachusetts Asbestos Notification Form ANF-001 00120273 Decal Number B. Facility Description (cont.) 5. NATIONAL REFRIGERATION a.Name of General Contractor WARWICK P.CM/Town 02886 d Zip Code AIG f.Contractor's Workers Comp.Insurer 6. What is the size of this facility? 3600 WEST SHORE DRIVE b.Address 401-737-2000 e Telephone Number(area cod and extension) WC5318622 q.Policy Number a.Square Feet 11/4/2011 h.Exp.Date lmm/dd/yyyy) b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): ACCUTECH INSULATION &CONTRACTING, I a.Name of Transporter LUDLOW c.City/Town 01056 d.Zip Cade 2. Transporter of asbestos-containing waste material RED TECHNOLOGIES a.Name of Transporter BLOOMFIELD c.City/Town 06002 d.Zip Code a-Refuse Transfer Station and Owner c City/Town d Zip Code MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 9000 MINERVA ROAD c.Final Disposal Site Address OH e.Slate 44688 f.Zip Code 100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 e.Telephone Number from removal/temporary site to final disposal site: 10 NORTHWOOD DRIVE b.Address 8602182428 e.Telephone Number b.Address e.Telephone Number b.Anal Disposal Site Location Owners Name WAYNESBURG d City/Town g.Telephone Number D. Certification The undersigned hereby states,under the p Ife of p j ry,that he/she has read the C Ith fM h It eg I f f th R I C tainm nt r Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information contained in this notification is true and correct ° to the best of his/her knowledge and belief. ° Z C anf001ap doc•10/02 FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 4135835500 i1IO LeMay •.Authorized Signature 2/3/2011 d.Date(mm/dd/yyyy) ACCUTECH INSULATION! e.Telephone Number f.Representing 100 STATE ST. BLDG 119, PO BOX 376 q.Address LUDLOW h.City/Town 01056 Zip Code Asbestos Notification Farm Page 3 of 3• Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. Commonwealth of Massachusetts Asbestos Notification Form ANF-001 ■ 100120283 Decal Number A. Asbestos Abatement Description a. Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied residence of four units or less? El Yes ❑No b. Provide blanket decal number if applicable: 2. Facility Location: HAMPSHIRE HEIGHTS a.Name of Facility Northampton c City/Town INSTRUCTIONS 3. Worksite Location: 1.All sections of this form must be completed in order to comply with 4. DEP notification requirements of 310 CMR7.15 5. and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 6.12 0 2 6. HAMPSHIRE HEIGHTS a.Building Name/Building Location MA d.State BLDG 3 b Building N Is the facility occupied? IA Yes ❑ No Asbestos Contractor: ACCUTECH INSULATION &CONTRACTING I a.Name LUDLOW c.City/Town AC000005 f DOS License Number 01056 d.Zip Code IJON HITE b.Facility Contact Person JULIO VENTURA a Name of On-Site Supervisor/Foreman N/A 7- a.Name of Project Monitor 8. 9 Blanket Decal Number 10 JACKSON STREET b.Street Address 01060 a Zip Code c.Wing 4015692277 L Telephone Number 1ST FLOOR d.Floor APT'S A&D a Room 100 STATE STREET b Address 4135835500 e.Telephone Number g. Contract Type: LA Written ❑Verbal N/A a.Name of Asbestos Analytical Lab 2/17/2011 a Project Start Date(mmldd/yyyy) AM-4PM Contact Person's Title AS001178 b.Supervisor/Foreman DOS Certification Number NIA b.Project Monitor DOS Certification Number N/A b.Asbestos Analytical Lab DOS Certification Number 2/17/2011 b.E nd Date(mm/de/yyyy) N/A c.Work hours Mon-Fri. 10 a What type of project is this? ❑ Demolition ❑Repair 0 Renovation ❑ Other, please specify: 11. a. Check abatement procedures: Glove bag ❑ Enclosure ❑ Cleanup ❑ Full containment ❑ Encapsulation ❑ Disposal only ❑Other, specify: d.Work hours Sat-Sun. b.Describe b.Describe 12. Is the job being conducted: 'A Indoors? ❑Outdoors? anfOolap.doc•10/02 Asbestos Notification Form•Page I of 3 SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH&REMOVE USING THE NE# 0 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120283 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed, or encapsulated: 0 a.Total pipes or ducts(linear ft) c.Boiler,breaching,duct,tank surface coatings A Corrugated or layered paper pipe insulation g.Spray-cm fireproofing Cloths,woven fabrics k.Thermal.solid core pipe insulation 4 b.Total other surfaces(square fl) Lin.ft Lin.ft Lin.R. Sq ft Sq.ft. Lin.ft. Lin.ft. Sq.ft d.Insulating cement t Trowel/Sprayer coatings 1 h.Transite board wall board S .ft. j Other,please specify'. Lin.ft. Lin.ft. Lin.ft. Lin.ft. Sq.ft. Sq.ft. Sq.ft. 4 Sq ft VAT Sq.ft I.Specify 14. Describe the decontamination system(s)to be used: 15 Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY& DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: N/A a.Name of DEP Official c.Date(mmrdd/yyyy)of Authorization N/A e.Name of DOS Official g Date(mm/dd/yyyy)of Authorization N/A b.Title N/A d DEP Waiver# N/A (DOS Official Title IN/A h.DOS Waiver# 17_ Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? l]Yes❑No ° B. Facility Description 0 1 Current or prior use of facility: RESIDENTIAL 2 Is the facility owner-occupied residential with 4 units 3. NORTHAMPTON HOUSING AUTHORITY a.Facility Owner Name 'NORTHAMPTON c.City/Town 4 'JOHN CONNERS a.Name of Facility Owner's On-Site Manager 'WARWICK 02886 01060 d.Zip Code anf001ap doe•10/02 c.City/Town d.Zip Code or less? ❑Yes 12 No 49 OLD SOUTH STREET b.Address 413-5844030 e.Telephone Number(area code and extension) 3600 WEST SHORE DRIVE b.On-Site Manager Address 401-737-2000 e.Telephone Number(area code and extension) Asbestos Notification Form•Page 2 of 3 U I Commonwealth of Massachusetts Asbestos Notification Form ANF-001 Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19000 0 100120283 Decal Number B. Facility Description (cont.) NATIONAL REFRIGERATION a.Name of General Contractor WARWICK c.City/Town 02886 d.Zip Code AIG f Contractors Workers Comp.Insurer 6. What is the size of this facility? 3600 WEST SHORE DRIVE b Address 401-737-2000 e.Telephone Number(area code and extension) 1 WC5318622 g.Policy Number a.Square Feet J 11/4/2011 h.Exp.Date(mm/dd/yyyy) b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): ACCUTECH INSULATION 8 CONTRACTING, I a.Name of Transporter LUDLOW a City/Town 01056 d.Zip Code 100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 e.Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: RED TECHNOLOGIES a.Name of Transporter 'BLOOMFIELD c.City/Town 06002 d.Zip Code a.Refuse Transfer Station and Owner C.City/Town d Zip Code MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 19000 MINERVA ROAD c.Final Disposal Site Address 1OH e.State 44688 L Zip Code 10 NORTHWOOD DRIVE b.Address 8602182428 e.Telephone Number b.Address e.Tele hone Number b.Final Disposal Site Location Owner's Name WAYNESBURG d City/Town g.Telephone Number D. Certification The undersigned hereby states,under the p Ices of perjury,that he/she has read the C o wealth of Massachusetts regulations f the Removal,Containment or E ps late of A b t 453 CMR 6.00 and 310 CMR 7.15,and that the information t d' th's off f ' t d t t th b t fh' /h k Idg db I' f • anfOOlap.doc•10/02 FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 14135835500 ii i' • '/ Aith LeMay r Authorized Signature 2/3/2011 d.Date(mm/dd/W W) ACCUTECH INSULATION e.Telephone Number f.Representing 100 STATE ST. BLDG 119, PO BOX 376 q Address LUDLOW h City/Town 01056 Zip Code Asbestos Notification Form•Page 3 of 3 U 0 Iii Commonwealth of Massachusetts Asbestos Notification Form ANF-001 Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. ■ 100120313 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? 12 Yes ❑No b. Provide blanket decal number if applicable: 2. Facility Location: HAMPSHIRE HEIGHTS a.Name of Facilit Northampton c.City/Town INSTRUCTIONS 3. Worksite Location: 1.All sections of this form must be completed in order to comply with 4. DEP notification requirements of 310 CMR 7.15 5. and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 6.12 0 6 7 a 9 'HAMPSHIRE HEIGHTS a.Building Name/Building Location MA d.State BLDG 4 b.Building ft Is the facility occupied? F4 Yes ❑No Asbestos Contractor: ACCUTECH INSULATION &CONTRACTING I a.Name LUDLOW a City/Town AC000005 C DOS License Number 01056 tltl.Zi Code JON HITE h.Facility Contact Person JULIO VENTURA a.Name of On-Site Superviso Foreman N/A a.Name of Project Monitor N/A a.Name of Asbestos Analytical Lab 2/18/2011 a.Project Start Date(mm/EC/yyyyl 7AM-4PM c.Work hours Mon-Fri. 0 10 a What type of project is this? 0 0 IL Z ❑ Demolition p Renovation ❑ Repair ❑Other, please specify: 11. a. Check abatement procedures: Glove bag ❑Enclosure ❑Cleanup ❑Full containment ❑ Encapsulation ❑ Disposal only ❑Other, specify: Blanket Decal Number 10 JACKSON STREET b.Street Address 01060 e.Zip Code c.Wing 4015692277 f.Telephone Number 1ST FLOOR d-Floor APT'S A&D e.Room 100 STATE STREET b.Address 4135835500 e.Telephone Number g. Contract Type: p Written ❑Verbal i.Contact Person's Title AS001178 b.Supervisor/Foreman DOS Cedir car on Number N/A b.Pro ed Monitor DOS Certification Number 1N/A b.Asbestos Analytical Lab DOS Certification Number 2/18/2011 b.E nd Date(mml tld/yyyy) N/A d.Work hours Sat-Sun. b.Describe b.Describe 12 Is the job being conducted: ❑ Indoors? ❑Outdoors? anf001apdoc•10/02 Asbestos Notification Form•Page 1 of 3 LiCommonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120313 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or encapsulated: 0 a Total pipes or ducts(linear f) c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing i.Cloths,woven fabrics k.Thermal,solid core pipe insulation 4 b. I otal other surfaces(square ft) Lin.ft. Lin.ft. Lin.ft Lin.ft Lin.ft. Sq.ft Sq.ft. d.Insulating cement L Trowel/Sprayer coatings h.Transite board,wall board S ft j.Other,please specify: VAT Lin.ft. Lin,ft Lin. Sq.ft. Lin.ft. 4 Sq.ft I.Specify 14. Describe the decontamination system(s)to be used SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH& REMOVE USING THE NO 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY& DELIVERED IN A SEALED VEHICL] 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: N/A a Name of DEP Official c.Date(mm/dd/yyyy)of Authorization N/A N/A b Title N/A d.DEP Waiver# N/A e.Name of DOS Official L DOS Official Title N/A g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver# 17 Do prevailing wage rates as per M.G.L.c. 149, §26, 27 or 27A-F apply to this project? 17 Yes❑No B. Facility Description 1 Current or prior use of facility: [RESIDENTIAL 2 Is the facility owner-occupied residential with 4 units or less? ❑Yes Z No 3 4 NORTHAMPTON HOUSING AUTHORITY a.Facility Owner Name NORTHAMPTON C.City/Town 01060 d.Zip Code JOHN CONNERS a Name of Facility Owners On-Site Manager WARWICK 02886 • anf001ap.doc•10/02 c.City/Town d.Zip Code 49 OLD SOUTH STREET b.Address 413-584-4030 e.Telephone Number(area code and extension) 3600 WEST SHORE DRIVE b On-Site Manager Address 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form•Page 2 of 3 Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19000 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100120313 Decal Number B. Facility Description (cont.) 5 NATIONAL REFRIGERATION a.Name of General Contractor WARWICK c.City/Town 02886 d.Zip Code AIG f.Contractor's Worker's Comp.Insurer 6. What is the size of this facility? 3600 WEST SHORE DRIVE b.Address 401-737-2000 e.Telephone Number(area code and extension) WC5318622 q.Policy Number a.Square Feet 11/4/2011 h.Exp.Date(mm/dd/yyyy) b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): ACCUTECH INSULATION 8 CONTRACTING, I a.Name of Transporter LUDLOW c.City/Town 01056 d.Zip Code 100 STATE ST. BLDG 119, PO BOX 376 b Address 4135835500 e.Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 3 4 RED TECHNOLOGIES a.Name of Transporter BLOOMFIELD c.GIN/Town D6002 d.Zip Code a.Refuse Transfer Station and Owner c.City/Town P d Zip Code MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 9000 MINERVA ROAD c.Final Disposal Site Address OH e.State 44688 f.Zip Code 10 NORTHWOOD DRIVE b Address 8602182426 e.Telephone Number b.Address e.Telephone Number b.Final Disposal Site Location Owners Name WAYNESBURG d.City/Town g.Telephone Number o D. Certification The undersigned hereby states,under the p It fp jrythth / h h dth o Commonwealth of Massachusetts regulations for the Removal.Containment or E p I l' fA b t 453 CMR 6.00 and 310 CMR 7.15,and that the information t d th' tf t ' t d t o t th best of his/her knowledge and belief. 0 z anf001ap.doc•10/02 FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 4135835500 e.Telephone Number LeMay b.Authorized Sign. ure 2/3/2011 d Date(mm/dd/yyyy) ACCUTECH INSULATION f Representing 100 STATE ST. BLDG 119, PO BOX 376 q.Address LUDLOW h.City/Town 1056 i.Zip Code Asbestos Notification Form•Page 3 of 3 II Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. EXT INSTRUCTIONS Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120320 Decal Number A. Asbestos Abatement Description a. Is this facility fee exempt-cilytown, district, municipal housing authority, owner-occupied residence of four units or less? AI Yes ID No b. Provide blanket decal number if applicable: 2. Facility Location: HAMPSHIRE HEIGHTS a-Name of Facility Northampton c.City/Town 3. Worksite Location: 1.All sections of this form must be completed in order to comply with 4. DEP notification requirements of 310 CMR 7.15 5. and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 6.12 6. a.Name of On-Site Supervisor/Foreman HAMPSHIRE HEIGHTS a.Building Name/Building Location Is the facility occupied? Asbestos Contractor: 0 MA d.State BLDG 5 b.Building# Yes D No ACCUTECH INSULATION &CONTRACTING I a.Name LUDLOW C.City/Town 01056 d.Zip Code AC000005 f.DOS License Number JON HITE h.Facility Contact Person Blanket Decal Number 10 JACKSON STREET b Street Address 01060 A Zip Code c.Wing 4015692277 f.Telephone Number 1ST FLOOR d.Floor APT'S A&D A Room 100 STATE STREET b.Address 4135835500 e.Telephone Number g. Contract Type: Written D Verbal JULIO VENTURA N/A 7- a.Name of Project Monitor N/A 8. a.Name of Asbestos Analytical Lab 0 9' a.Pr 2/18/2011 0 ect S rt Dat mm/dd 11 7AM-4PM i.Contact Person's Title AS001178 b.Supervisor/Foreman DOS Certification Number N/A b.Project Monitor DOS Certification Number N/A b.Asbestos Analytical Lab DOS Certification Number 2/18/2011 aE nd Date(mm/dd/yyyyL NIA c.Work hours Man-Fri. o 10 a What type of project is this? D Demolition GI Renovation • Repair D Other, please specify: 11. a. Check abatement procedures: 0 Z C Glove bag Enclosure Cleanup Full containment D Encapsulation D Disposal only D Other, specify: d.Work hours Sat-Sun. b.Describe b.Describe 12. Is the job being conducted: fl Indoors? ❑Outdoors? anf0olap doc•10/02 Asbestos Notification Form•Page t of 3 0 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120320 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or encapsulated: a.Total pipes or ducts(linear ft) c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing i.Cloths,woven fabrics E Thermal,solid core pipe insulation b I otal other surfaces(square ft) Lin.ft. Lin.ft. Lin.ft Lin.ft. Lin ft Sq ft. Sq.ft. 1 d Insulating cement f.Trowel/Sprayer coatings 5q ft b.Transite board,wall board j.Other,please specify: Lin.ft Lin.ft. Lin.ft. Sq ft. Sq.ft. q. 4 VAT Sq.ft. I.Specify 14. Describe the decontamination system(s)to be used SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NEB 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY&DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: N/A a.Name of DEP Official N/A b.Title c Date(mmlddlyyyy)of Au rization N/A e Name of DOS Officia g.Date(mmlddlyyyy)of Authorization WA d.DEP Waiver if N/A f.DOS Official Title N/A h.DOS Waiver# O 17 Do prevailing wage rates as per M.G.L.c. 149, §26, 27 or 27A—F apply to this project? ❑Yes❑No B. Facility Description O 1 Current or prior use of facility 0 RESIDENTIAL 2 Is the facility owner-occupied residential with 4 units or less? ❑Yes 0 No 3 a Facility Owner Name NORTHAMPTON HOUSING AUTHORITY o NORTHAMPTON u- z 4. c.City/Town 01060 d.Zip Code 49 OLD SOUTH STREET b.Address JOHN CONNERS anf001ap.doc•10102 a.Name of Facility Owne WARWICK c.City/Town On-Site Manager 413-5844030 e.Telephone Number(area code and extension) 3600 WEST SHORE DRIVE b.On-Site Manager Address 02886 Zip Code 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form•Page 2 of 3 Commonwealth of Massachusetts t Asbestos Notification Form ANF-001 Vote:Transfer >tations must :empty with the Solid Waste Division Regulations 310 DMR 19 000 n 0 0 100120320 Decal Number B. Facility Description (cont.) NATIONAL REFRIGERATION a.Name of General Contractor WARWICK c.City/Town 02886 d.Zip Code AIG L Contractors Workers Comp.Insurer 6. What is the size of this facility? 3600 WEST SHORE DRIVE b.Address 401-737-2000 e.Telephone Number(area code and extension) 1WC5318622 11/4/2011 g Policy Number M1.Exp.Date(mmltldlyyyy) a.Square Feet b.Number of Boors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site Of necessary): ACCUTECH INSULATION &CONTRACTING, I a.Name of Transpoder 'LUDLOW c.City/Town 01056 d.Zip Code 1100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 e.Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 4 RED TECHNOLOGIES a-Name of Transporter 'BLOOMFIELD c.City/Town 06002 d.Zip Code 1 10 NORTHWOOD DRIVE b.Address 8602182428 e.Telephone Number a.Refuse Transfer Station and Owner c.City/Town MINERVA ENTERPRISES INC a-Final Disposal Site Location Name 9000 MINERVA ROAD c.Final Disposal Site Address 1 d.Zip Code b.Address e.Tele•hone Number OH e.State 144688 f.Zip Code D. Certification The undersigned hereby states,under the 0 penalties of perjury,that he/she has read the 0 C mmonwealth of Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. 0 0 LL Z C • anf001ap.doc-10/02 b.Final Disposal Site Location Owner's Name WAYNESBURG . d.City/fown g.Telephone Number FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 4135835500 ith LeMay b Authorized Signature 2/3/2011 d Date(mrndd/yyyy) ACCUTECH INSULATION e.Telephone Number (.Representing 100 STATE ST. BLDG 119, PO BOX 376 A.Address LUDLOW h.City/Town 01056 Zip Code Asbestos Notification Form•Page 3 of 3 Important: Mien filling out corms on the :omputer,use only the tab key to move your :ursor-do not ise the return Key. INSTRUCTIONS Commonwealth of Massachusetts Asbestos Notification Form ANF-001 ■ 100120321 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? Yes ❑No b.Provide blanket decal number if applicable: 2. Facility Location: HAMPSHIRE HEIGHTS a.Name of Facility Northampton c.City/Town 3. Worksite Location: 1.All sections of this form must be completed in order to comply with 4 DEP notification requirements of 310 CMR 7.15 5 and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 6.12 6 7 HAMPSHIRE HEIGHTS a.Building Name/Building Location Is the facility occupied? Asbestos Contractor: MA d State BLDG 6 b.Building# Yes ❑No ACCUTECH INSULATION & CONTRACTING I a.Name LUDLOW c.City/Town AC000005 01056 f.DOS License Number JON HITE Blanket Decal Number 10 JACKSON STREET b Street Address 01060 e.Zip Code c.Wing 4015692277 C Telephone Number 1ST FLOOR d Floor APT'S A& D e.Room 100 STATE STREET b.Address 4135835500 d.Zip Code e.Telephone Number g. Contract Type: Written ❑Verbal '4 h.Facility Contact Person JULIO VENTURA a.Name of On-Site Supervisor/Foreman N/A a.Name of Project Monitor IN/A 6- a.Name of Asbestos Analytical Lab 0 tL z 2/18/2011 a.Project Start Date(mm/dd/yyyy) 7AM-4PM c.Work hours Mon-Fn. 10 a What type of project is this? ❑ Demolition 4A Renovation ❑ Repair ❑Other, please specify: 11. a. Check abatement procedures: 12 Glove bag ❑ Enclosure ❑ Cleanup ❑ Full containment ❑ Encapsulation ❑ Disposal only ❑ Other, specify: Contact Person's Title AS001178 b.Supervisor/Foreman DOS Certification Number N/A A Project Monitor DOS Certification Number N/A b.Asbestos Analytical Lab DOS Certification Number 2/18/2011 b E nd Date(mm/dot/yyyy) N/A d Work hours Sat-Sun. b.Describe b.Describe 12. Is the job being conducted: [ Indoors? ❑Outdoors? anPo0lap.doc•10/02 Asbestos Notification Form-Page 1 of 3 SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN,LAY DROP CLOTH &REMOVE USING THE NEG 0 0 tL z Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 100120321 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or encapsulated: to Total pipes or ducts(linear ft) c.Boiler,breaching,duct,tank surface coatings a Corrugated or layered paper pipe insulation g.Spray-on fireproofing i.Cloths,woven fabrics k.Thermal,solid core pipe insulation itt b. I olal other surfaces(square ft) Lin ft Lin.ft. Sq.ft. Lin.ft. Lin.ft d Insulating cement f.Trowel/Sprayer coatings h.Transite board,wall board j.Other,please specify: Lin.ft. Lin.ft_ Lin.ft. Lin.ft. Sq ft q. 4 Sq.ft VAT Lin.ft. Sq.ft. I.Specify 14. Describe the decontamination system(s)to be used: 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY& DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: N/A a.Name of DEP Odic c.Dale(mddlyyyy S )of Authorization N/A e.Name of DOS Official N/A b.Title N/A d.DEP Waiver W cN/A DOS Official Tile N/A g.Date(mrTdd/yyyy)of Authorization h.DOS Waiver 7r 17. Do prevailing wage rates as per M.G.L. c. 149,§26, 27 or 27A—F apply to this project? 61 Yes Li No B. Facility Description 1 Current or prior use of facility: 2. Is the facility owner-occupied residential with 4 units or less? 149 OLD SOUTH STREET RESIDENTIAL 3 4 NORTHAMPTON HOUSING AUTHORITY a.Facility Owner NORTHAMPTON c.City/Town 01060 d.Zip Code JOHN CONNERS a.Name of Facility Owner's On-Site Manager 02886 (WARWICK c.City/Town ❑Yes No b.Address 1413-5844030 e.Telephone Number(area code and extension) 3600 WEST SHORE DRIVE b.On-Site Mana er Andress anfOOlap doe•10/02 d.Zip Code 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Farm•Page 2 of 3 Vote:Transfer Stations must ;amply with the Solid Waste Division Regulations 310 CMR 19.000 M Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100120321 Decal Number B. Facility Description (cont.) NATIONAL REFRIGERATION a.Name of General Contractor WARWICK c.City/Town AIG f.Contractors Worker's Comp.Insurer What is the size of this facility? 01060 d.Zip Code 3600 WEST SHORE DRIVE b.Address 401-737-2000 e.Telephone Number(area code and extension) WC5318622 Irp.Policy Number a.Square Feet 1114/2011 h.Exp.Date(mm/dd/yyyy) 1 b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site Of necessary): ACCUTECH INSULATION &CONTRACTING, I a.Name of Transporter LUDLOW c.CityiTown 01056 d Zip Code 100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 e Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: RED TECHNOLOGIES a.Name of Transporter BLOOMFIELD 3. I 4 a City/fown 06002 d Zip Code 10 NORTHWOOD DRIVE b.Addres 8602182428 e Telephone Number a.Refuse Transfer Station and Owner c.City/Town MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 9000 MINERVA ROAD c.Final Disposal Site Address Zp Code b.Address OH e.State 44688 f.Zip Code D. Certification The undersigned hereby states, under the penalties of perjury,that he/she has read the ° Commonwealth of Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information contained in this notification is true and correct ° to the best of his/her knowledge and belief. LL 2 C anf001ap.doc•10/02 e.Telephone Number b.Final Disposal Site Location Owner's Name WAYNESBURG d.City/Town g Telephone Number FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 4135835500 e.Telephone Number 2/3/2011 d.Date(mm/dd/vyw) ACCUTECH INSULATION f Represenfinq 100 STATE ST. BLDG 119, PO BOX 376 q.Address LUDLOW h.City/Town 01056 Zip Code Asbestos Notification Form•Page 3 of 3 II Commonwealth of Massachusetts Asbestos Notification Form ANF-001 1porlant: 'hen filling out rms on the >mauter,use ily the tab key move your >rsor-do not se the return ey. b VSTRUCTIONS 100120330 Decal Number A. Asbestos Abatement Description a. Is this facility fee exempt-city,town,district, municipal housing authority,owner-occupied residence of four units or less? O Yes ❑No All sections of this Drm must be ompleled in order a comply with )EP notification equirements of 310 ;MR 715 and the Division >f Occupational Safety(DOS) ratification 'egwrements of 453 SMR 6.12 1. b. Provide blanket decal number if applicable: 2. Facility Location: 'HAMPSHIRE HEIGHTS a.Name of Facility 'Northampton c.City/Town Blanket Decal Number 1 110 JACKSON STREET 3. Worksite Location: 'HAMPSHIRE HEIGHTS 11 a.Building Name/Building Location 'MA d.State 'BLDG 7 b.Building It 4. Is the facility occupied? fl Yes ❑ No 5. Asbestos Contractor: 'ACCUTECH INSULATION& CONTRACTING I' a Name LUDLOW c City/Town 1AC000005 f DOS License Number J 01056 d.Zip Code b.Street Address 01060 e.Zip Code c Wing 14015692277 f.Telephone Number 1ST FLOOR d.Floor APT'S A&DI a Room 1100 STATE STREET b.Address 4135835500 e.Telephone Number g. Contract Type: TA Written ❑Verbal 'JON HITE h.Facility Contact Person 'JULIO VENTURA 6 a.Name of On-Site Supervisor/Foreman 'N/A 7' a Name of Project Monitor 8. 1N/A a.Name of Asbestos Analytical Lab '2/21/2011 0 9' a.Project Start Date(mmttldlyyyy) 01 7AM-4PM c.Work hours Mon-Fri. 0 10 a What type of project is this? J 0 0 I.Contact Person's Title 1A5001178 b Supervisor/Foreman DOS Certification Number N/A b.Project Monitor D05 Certification Number 1N/A b.Asbestos Analytical Lab DOS Certification Number 12/21/2011 El Demolition TA Renovation FT Repair ❑ Other, please specify: 11. a.Check abatement procedures: F' Glove bag ❑Encapsulation ❑ Enclosure ❑ Disposal only ❑ Cleanup ❑Other, specify: LL ❑ Full containment 12. Is the job being conducted: Indoors? LJ Outdoors? 2 b.E nd Date N/A d.Work hours Sat-Sun. mmr dd Describe b.Describe anf00lap doc•10102 Asbestos Notification Form.Page 1 of 31II Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • 1100120330 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or encapsulated: 4 a.Total pipes or ducts(linear ft) b. fatal other sudaces(square ft) c.Boiler,breaching,duct,tank d.Insulating cement surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing I.Cloths,woven fabrics k.Thermal,solid core pipe insulation Lin ft. Lin.ft. Lin.ft. Sq.ft. Sq.ft. Lin. Sq.ft. Lin.ft. S ft. Sq.ft. 14. Describe the decontamination system(s)to be used [SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN,LAY DROP CLOTH 8 REMOVE USING THE NE( f.Trowel/Sprayer Coatings h Transite board,wall board Other,please specify' Lin.ft. Lin ft. L Lin.ft. Sq.ft. 1 q. Lin.ft 4 Sq.ft VAT I.Specify 15, Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY 8 DELIVERED IN A SEALED VEHICLI 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: J 1 g. Date(mMdd/yyyy)of Authorization ° 17. Do prevailing wage rates as per M.G.L. c N/A a.Name of DFP Official c.Date(mm/ddlyyyy)of Authorization IN/A e Name of DOS Official 'NIA b Title 1N/A d DEP Waiver# N/A TI—JCS Offal Title N/A h.DOS Waiver# 49, §26, 27 or 27A-F apply to this project? • Yes❑No o B. Facility Description 0 tz 0 'RESIDENTIAL 1 Current or prior use of facility: 2 Is the facility owner-occupied residential with 4 units or less? ❑Yes 61 No 149 OLD SOUTH STREET 3 a.Facility Owner Name b.Address E413-584-1030 e Telephone Number(area code and extension 3600 WEST SHORE DRIVE b.On Site Manager Address 1 02886 1 1401-569-2277 d.Zip Code e.Telephone Number(area code and extension) Asbestos Notification Form Page 2 of 3 'NORTHAMPTON HOUSING AUTHORITY 1 O `NORTHAMPTON c.city/rown JOHN CONNERS a Name of Facility Owne 4 101060 d.Zip Code On Site Manager • WARWICK • c.City/Town anf001ap riot•10102 ( 1 as:Transfer ations must mply with the lid Waste vision agulations 310 NR 19.000 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 1100120330 Decal Number B. Facility Description (cont.) 'NATIONAL REFRIGERATION a.Name of General Contractor 'WARWICK c.City/Town 1AIG L Contractor's Worker's Comp.Insurer 6. What is the size of this facility? 102886 d Zip Code 13600 WEST SHORE DRIVE b.Address 1401-737-2000 e.Telephone Number(area code and extension) 1 1 W C5318622 1 111/4/2011 E.g.Policy Number a.Square Feet h.Exp.Date(mnJdd/yyvy)l 0.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site (if necessary): IACCUTECH INSULATION 8 CONTRACTING,11 a.Name of Transporter 1LUDL0W c.City/Town 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 101056 d.Zip Code 1100 STATE ST. BLDG 119, PO BOX 376 b.Address 14135835500 e.Telephone Number 'RED TECHNOLOGIES a.Name of Transporter 'BLOOMFIELD C.Ciy/Town 3. 1 106002 d.Zip Code a Refuse Transfer Station and Owner City/Town MINERVA ENTERPRISES INC a.Final Disposal Site Location Name d.Zip Code 19000 MINERVA ROAD c.Final Disposal Site Address 1OH e.State m • D. Certification The undersigned hereby states,under the o penalties of perjury,that he/she has read the ° Commonwealth of Massachusetts regulations for the Removal,Containment or • Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information contained in this notification is true and correct ° to the best of his/her knowledge and belief. 144688 f.Zip Code IL 2 a anfoolapdoc•10/02 110 NORTHWOOD DRIVE b.Address 8602182428 e.Telephone Number O.Address e.Tel ephone Number b.Final Disposal Site Location Owner's Name WAYNESBURG d.City/Town g.Telephone Number 'FAITH LEMAY a.Name 1ADMIN ASSIST c.Position/Title 14135835500 e.Telephone Number 100 STATE ST. BLDG 1 q.Address 'LUDLOW h.City/Town th LeMay 0.Authorized Signature 1214/2011 d.Date(mm/dd/vy➢y) IACCUTECH INSULATION( f.Re sentinp 19, PO BOX 376 1 01056 Zip Code Asbestos Notification Form•Page 3 of 3 II (HAMPSHIRE HEIGHTS a Name of Facility !Northampton c.Ciry/Town (4135835500 e Telephone Number g. Contract Type: F7 Written ❑Verbal orient: to filling out s on the iputer,use the tab key love your or-do not the return .TRUCTIONS Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • [100120335 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? GI Yes ❑No b. Provide blanket decal number if applicable: 2. Facility Location: 3. Worksite Location: UI sections of this must be isolated in order 'amply with 4. P notification irements of 310 IR 7.15 5. i the Division Occupational fety(DOS) ineation puirements of 453 AR 612 (HAMPSHIRE HEIGHTS a Building Name/Building Location Is the facility occupied? Asbestos Contractor: t2 1MA d State BLDG B 1 b Building# Yes ❑No LACCUTECH INSULATION &CONTRACTING I a.Name LUDLOW c.City/Town AC000005 01056 d.Zip Code f DOS License Number (JON HITE h.Facility Contact Person (JULIO VENTURA 6. a.Name of On-Site Supervisor/Foreman 1N/A 7. a.Name of Protect Monitor IN/A 8' a.Name of Asbestos Analytical Lab 9 1212112011 a.Project Start Date(mmlddlyyyy) 17AM-4PM Blanket Decal Number PO JACKSON STREET b.Street Address 101060 e.Zip Code c Wing 14015692277 Telephone Number (1ST FLOOR! d Floor IAPTS A&D 1 e Room HO STATE STREET b.Address 1 1 c.Work hours Mon-Fri. 10 a What type of project is this? O ❑ Demolition • ❑ Repair 0 0 LL 2 Renovation ❑ Other, please specify: 11. a. Check abatement procedures: Glove bag ❑ Enclosure ❑Cleanup ❑ Full containment ❑Encapsulation ❑ Disposal only ❑Other, specify: i.Contact Person's Title AS001178 b.Su ervisor/Foreman DOS Cenification Number N/A b.Project Monitor DOS Certification Number IN/A b.Asbestos Analytical Lab DOS Certification Number 12/21/2011 b.E nd Date(min/dd/yyyy) 1N/A d Work hours Sat-Sun. b.Describe b.Describe 12. s the job being conducted: 0 Indoors? - Outdoors? anf001ap doc•10/02 Asbestos Notification Form•Page 1 of 3 U Commonwealth of Massachusetts Asbestos Notification Form ANF-001 -- • 100120335 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or encapsulated' — 0 0 N i0 O.Total pipes or ducts(linear c.Boiler,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing Cloths,woven fabrics Lin. Lin.ft. LLin.ft. Lin.ft. k.Thermal,solid core pipe Lin.tt. insulation 14. Describe the decontamination system(s)to be used SEAL CRITICALS WI 6 MIL POLY, PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NEG 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): ACM TO BE DOUBLE BAGGEDIWRAPPED IN 6 MIL POLY&DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: d Insulating cement Sq.if Sq.ft. q.ft Sq.ft. I Sq.ft. .specify f.Trowel/Sprayer coatings A Transite board,wall board j.Other,please specify'. VAT Lin.ft. _ Sq ft N/A a Name of DE O mia c.Date(mm/ddlyyyyl of Autho N/A e.Name of DOS Official N/A d DEP Waiver k N/A clal itie N/A — g.Date(mmltldlyyyy)of Authorization h.DOS Waiver p 17. Do prevailing wage rates as per M.G.L.c. 149,§26, 27 or 27A—F apply to this project? B. Facility Description (RESIDENTIAL 1. Current or prior use of facility 2 Is the facility owner-occupied residential with 4 units or less? Yes 2 No 3. 0 0 LL :Q 4 NORTHAMPTON HOUSING AUTHORITY a.Facila y Owner Name 01060 NORTHAMPTON frown 49 OLD SOUTH STREET b.Address 4135844030 one Number d Li. Code JOHN CONNERS a.Name of Facili ner's On-Site Manager WARWICK 02886 d.Zip Code o.City/Town ■ anroolapeoc•10102 • Yes❑No code and extensio 3600 WEST SHORE DRIVE b On-Site Manager 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form-Page 2 of 3 II Commonwealth of Massachusetts 1 L r.Transfer ions must ply with the d Waste sion ulations 310 R 19 000 Asbestos Notification Form ANF-001 B. Facility Description (cont.) 100120335 Decal Number NATIONAL REFRIGERATION 3600 WEST SHORE DRIVE b.Address 5' a.Name or General Contractor WARWICK 401-737-2000 C ty/r d p .Z Code e.Telephone Number(area code an e201sion WC5318622 AIG g-Policy Number f.Contractor Worker's Comp.Insurer ( 6. What is the size of this facility? a.Square Feet b.Number or floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): 100 STATE ST. BLDG 119,PO BOX 376 b.Address 4135835500 0 102886 ( 1 h.Exp.Date(mm/ddlyyyv) ACCUTECH INSULATION&CONTRACTING, I a N fTranspoder LUDLOW a.Zip Code e Telephone Number c Cityrtown 2. Transporter of asbestos-containing waste material from 0 removal/temPorary site Rite to final disposal site: RED TECHNOLOGIES b.Address a.Name of Transporter BLOOMFIELD 06002 J 8602182428 d Zi.Corte e.Telephone Number c Ci Rown 1 (__— 3. .—.—. _.._. b.Address 101056 a.Refuse Transfer Station and Owner c.Ci flown MINERVA ENTERPRISES INC sal Site Location Name a-Final Di 9000 MINERVA ROAD c.Final Dis osal Slte Address OH e.State • D. Certification A d Zi.Code 44688 L Zip Code Tele hone Number _ b.Fina Di osal Site Location WAYNESBURG d Clty/To wn g Telephone Number The undersigned hereby states,under the o penalties of perjury,that he/she has read the O Commonwealth of Massachusetts regulations for the Removal, Containment or • Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information contained in this notification is true and correct o to the best of his/her knowledge and belief. 0 LL z C antoolap.doc•10/02 (FAITH LEMAY a.Name ADMIN ASSIST c Position/Title 4135835500 e Tele.hone Number I.Re.resenti 100 STATE ST.BLDG 119,PO BOX 376 er Name F. h LeMay _.. • Authorized Signature 214/2011 A• CCUTECH g LUDLOW Address h.City/Town 01056 Zip Code Asbestos Notification Form•Page 3 of 3 U 1100120337 I— Commonwealth of Massachusetts Asbestos Notification Form ANF-001 tent: filling out on the (ter,use e tab key ye your r-do not to return RUCTIONS • Decal Number A. Asbestos Abatement Description 1. a. Is this facility fee exempt-city,Mown, district,municipal housing authority,owner-occupied residence of four units or less? WI Yes ❑No b.Provide blanket decal number if applicable: 2. Facility Location: sections of at 3. [HAMPSHIRE HEIGHTS a.Name of Facility [Northampton O.city/rown Worksite Location: [HAMPSHIRE HEIGHTS must be a.Building Name/Building Location doted in order .mpl1 with 4 notification iremems of 310 5 t 7.15 the Division ccupational baton tirements of 453 6.12 0 0 0 Is the facility occupied? Asbestos Contractor: [ACCUTECH INSULATION &CONTRACTING I 1 0 1MA d State 'BLDG 9 b.Building k Yes ❑No a.Name LUDLOW c.Cityfrown AC000005 f.DOS License Number 101056 d.Zip Code 'JON HITE h.Facility Contact Person [JULIO VENTURA 6' a.Name of On-Site Supervisor/Foreman [NIA 7. a.Name of Project Monitor N/A 8. a.Name of Asbestos Analytical Lab 2121/2011 9 P led Start Dale Immldtllyyyy) 8AM-4PM c.Work hours Mon-Fri. 10. a.What type of project is this? o ❑ Demolition ❑Repair 0 U- z iC Blanket Decal Number 110 JACKSON STREET b.Street Address 101060 e.Zip Code c Wing 14015692277 f Telephone Number 1ST FLOOR d.Floor [APT'S A&D 1 e Room 1100 STATE STREET b.Add res 4135835500 e.Telephone Number g.Contract Type: Fl Written ❑Verbal 1 li.Contact Person's Title 1A5001178 b.Supervisor/Foreman DOS Certification Number 1 1N/A b.Project Monitor DOS Certification Number [NIA b.Asbestos AnaMical Lab DOS Certification Number 12/2112011 .- b. ne ot 1 1 am yyyy) 1 N/A d.Work hours Sat-Sun. 1 Renovation ❑Other, please specify'. 11. a. Check abatement Glove bag ❑ Enclosure ❑Cleanup ❑Full containment 12 Is the job being conducted: procedures: ] Encapsulation ❑Disposal only ❑ Other,specify: • anrootap.doc•131/02 b.Describe b.Describe Ed Indoors? U Outdoors? Asbestos Notification Form•Page 1 of 3 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100120337 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or encapsulated' 0 o a o er su aces square a. otalpipes or ducts(linear tt) c.Boiler,breaching,duct,tank S fl d.Insulating cement surface coatings Lm fr e.Corrugated or layered paper Li_.it. pipe insulation g.Spray-on fireproofing I.Cloths,woven fabrics k.Thermal,solid core pipe insulation 14. Describe the decontamination system(s)to be used: SEAL CRITICALS W/6 MIL POLY, PRE-CLEAN,LAY DROP CLOTH 8 REMOVE USING THE NE 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(9): ACM TO BE DOUBLE BAGGED/WRAP- r �N 6 MIL POLY 8 DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: Lin ft. Lin n. L Trowel/Sprayer coatings Sq ry, Sq.ft. S Sq ft. It Transite board,wall board j.Other,please specify: VAT I.Specify • Lin.tt. Sq — Lin.ft in h. Lin.ft. Sq ft Sq.tt. 4 c.Date(mmidd of Authorization N/A e Name of DOS Official N/A b.Title NIA d.DEP Waiver# NIA pOSO icial Title NIA g.Date(mMdtllyyyy)of Authorization h.Dos waiver# ry 26, 27 or 27A—F apply to this project? 171 Yes l No • 17. Do prevailing wage rates as per M.G.L. c. 149,§ O B. Facility Description N RESIDENTIAL O 1 Current or prior use of facility: 0 0 i¢ 2. Is the facility owner-occupied residential with 4 units or less? LI Yes NORTHAMPTON HOUSING AUTHORITY Facili Owner Owner Name NORTHAMPTON c i /Town JOHN CONNERS Owner's On-Site Manager 01060 a.Name of Facili WARWICK a City/Town anf0olapdoc•10102 Z Code F' No 49 OLD SOUTH STREET bb.Address 413-584-4030 e.Tele•hone Number area code and ex 3600 WEST SHORE DRIVE b.On-Site ana er AddresS 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form Page 2 o13 d.Zip Code rLL Transfer ions must ply with the d Waste sion rylations 310 R 19.000 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 B. Facility Description (cont.) NATIONAL REFRIGERATION a.Name of General Contractor WARWICK AIG f.Contractors Workers Comp.Insurer 6. What is the size of this facility? C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): 5. n C Decal Number 3600 WEST SHORE DRIVE b.Address 401-737-20 00 e.Tele p floilber area code and extension WC5318622 11(4/2011 h Fop D t ( ldd/mY) mm P I'ry Number a.Square Feet b.Number of floors ACCUTECH INSULATION 8 CONTRACTING, a.Name of Trans Oder LUDLOW c.City/Town 2. Transporter of asbestos-containing waste material RED TECHNOLOGIES a.Nam On_ poter BLOOMFIELD 01056 d.Zip Code 00 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 e.Telephone Number from removal/temporary site to final disposal site: 10 NORTHWOOD DRIVE b Addre 8602182428 e.Telephone Number 4 a.Refuse Transfer d Owner b.Adtlress e.Telephone Number Ci flown MINERVA ENTERPRISES INC a.Final ors osal Site Location Name 9000 MINERVA ROAD c.Final Dis sal Site Address OH e.State D. Certification • The undersigned hereby states, under the o penalties of perjury,that he/she has read the o Commonwealth of Massachusetts regulations for the Removal,Containment or • Encapsulation of Asbestos,453 CMR 6.00 and • 310 CMR 7.15,and that the information contained in this notification is true and correct • to the best of his/her knowledge and belief. ao 2 44688 f.Zip Code b.Final D Site Location Owner WAYNESBURG d CitV/To n g.Telephone Number anf001ap.doc•10102 FAITH LEMAY a Name ADMIN ASSIST Position/Title 4135835500 --e.Tele•bone Number 100 STATE E S?_BLDG? Address s LUDLOW___._____ h.City/Town Authodzed Si 214/2011 ACCUTECH INSULATION (.Re•resent 19, PO BOX 376 01056 Zip Code Asbestos Notification Form•Page 3 of 3 U 101056 rtant filling out on the titer,use w Ve tab key we your rt-do not he return RU TIONS Commonwealth of Massachusetts Asbestos Notification Form ANF-001 II sections of Nis mu t a.Budding Name/Building Location . ,mplyin order with 4. Is the facility occupied? 3 npy no fiton aI5nts of 5. Asbestos Contractor >. 5 ra. ■ 1100120338 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? 151 Yes ❑No b. Provide blanket decal number if applicable: 2. Facility Location: 'HAMPSHIRE HEIGHTS a.Name of Facility 'Northampton c.City/Town 3. Worksite Location: 'HAMPSHIRE HEIGHTS the Division )ccupational ey( OS) fica on uirements of 453 R 612 rA MA d.State 'BLDG 10 b.Building if Yes ❑No 'ACCUTECH INSULATION&CONTRACTING I' a.Name 'LUDLOW c.OityITown LC000005 I.DOS License Number LJON HITE It Facility Contact Person 'JULIO VENTURA 6. a.Name of on-Site Supervisor/Foreman LN/A 7. a Name of Project Monitor N/A 6. a.Name of Asbestos Analytical Lab '2/22/2011 9 a.Project Start Date(mm/dd/yyyy) O 7AM-4PM c.Work hours Mon-Ed. 10 a What type of project is this? d.Zip Code o ❑ Demolition Renovation ❑ Repair ❑Other, please specify: ✓ 11. a. Check abatement procedures: D 0 LL TA Glove bag ❑Enclosure ❑ Cleanup ❑ Full containment 12. Is the job being conducted: 17 Indoors? ❑Outdoors? ❑ Encapsulation ❑ Disposal only (l Other,specify: Blanket Decal Number '10 JACKSON STREET b.Street Add '01060 e.Zip Code c.Wing 14015692277 4 Telephone Number 11ST FLOOR' d Floor 'APT'S A&D e.Room LI 00 STATE STREET b.Address 4135835500 e.Telephone Number g.Contract Type: Written ❑Verbal i.Contact Person's Title [AS001178 b.Supervisor/Foreman DOS Certification Number 'NIA b.Project Monitor DOS Certification Number 'N/A b.Asbestos Analytical Lab DOS Cedifiwtion Number 2/22/2011 b.E nd Date(mm/del/ray) 'N/A d.Work hours Sat-Sun. b.Describe b.Describe anfoOlap.doc•10102 Asbestos Notification Form•Page I of 3 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 • A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or encapsulated' 0 T3tal pipes or ducts(linear ft) b.l otal other surfaces(square ft) d.Insulating cement Sq.ft. c.Bolter,breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation 9.Spray-on fireproofing i.Cloths,woven fabrics k.Thermal,solid core pipe insulation 14. Describe the decontamination system(s)to be used: SEAL CRITICALS W/6 MIL POLY,PRE-CLEAN, LAY DROP CLOTH &REMOVE USING THE NE 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR Lin.ft Sq.ft. Lin.It un.n. Lin.ft Lin.ft. Sq.ft. f.Trowel/Sprayer coatings h.Transite board,wallboard j.Other,please specify: s n VAT Sq ft I.Sae* Lin.ft. L_ Lin.ft. Lin.ft. Lin Sq.ft. 4 Sq 6.14(2)(g): ACM TO BE DOUBLE BAGGEDIWRAPPED IN 6 MIL POLY 8 DELIVERED IN A SEA LED VEHICL. 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: N/A Title N/A d.DEP Waiver 14 _�_--- N/A f.DOS Official Title N/A a.Name of DEP Official c.Date( mlddlyyyy)of Authorization N/A e.Name of DOS Official g.Date(mmlddlyyyy)of Authorization N 17. Do prevailing wage rates as per M.G.L.c. 149, §26,27 or 27A—F apply to this project? 0 Yes El No 0 B. Facility Description iN io 1. Current or prior use of facility: 2. Is the facility owner-occupied residential with 4 units or less? ❑Yes RI No NORTHAMPTON HOUSING AUTHORITY N/A _ h.DOS Waiver ff 0 0 0 IQ RESIDENTIAL 4 JOHN CONNERS a Name of Foam Owner s On-Site Manage_ WARWICK 02886 C.City/Town d.Zip Code anfOOl ap dOC•10102 49 OLD SOUTH STREET bb.Address 4135844030 e.Tele.hone Number e andexten 3600 WEST SHORE DRIVE r. O -S'1 „. 401-569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form-Page 2 of 3 `WARWICK c.C'M/Town 1AIG f.Contractor's Workers Camp.Insurer 6. What is the size of this facility? 19000 MINERVA ROAD c.Final Disposal Site Address Transfer ions must ply with the d Waste Pon 'Wagons 310 R 19000 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 N00120338 Decal Number B. Facility Description (cont.) (NATIONAL REFRIGERATION 5. a.Name of General Contractor 13600 WEST SHORE DRIVE b.Address 102886 1401-737-2000 e.Telephone Number(area code and extension) 1 W C 5318622 1 111/4/2011 g.Policy Number h.Exp.Date(mMdyyy) d/y 1 1 1 1 a.Square Feet b.Number of floors d Zip Code C. Asbestos Transportation and Disposal i. Transporter of asbestos-containing material from site to temporary storage site Of necessary): 1100 STATE ST. BLDG 119, PO BOX 376 1ACCUTECH INSULATION &CONTRACTING,11 a.Name of 1 LUDLOW c.C Frown er 2. Transporter of asbestos- b.Address 01056 1 14135835500 d Zip Code e.Telephone Number containing waste material from removal/temporary site to final disposal site: 'RED TECHNOLOGIES a.Name of Transporter 18LOOMFIELD c.City/Town 3. 1 a.Refuse Transfer Station and Owner 1 NO NORTHWOOD DRIVE b.Address 06002 1 18602182428 d.Zip Code e.Telephone Number b.Address _.—-- c.City/Town d Zip Code 4. 1_MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 1OH e.State 144688 f.Zip Code n 0 O D. Certification N The undersigned hereby states,under the o penalties of perjury,that he/she has read the ° Commonwealth of Massachusetts regulations for the Removal.Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15,and that the information contained in this notification is true and correct o to the best of his/her knowledge and belief. 0 u. z II ant=ap.doc•10102 e.Telephone Number b.Final Disposal Site Location Owner's Name WAYNESBURG d.City/Town g.Telephone Number FAITH LEMAY a.Name ADMIN ASSIST c.Position/Title 4135835500 B.Telephone Number 1100 STATE ST. BLDG 119, Address q 'LUDLOW h.City/Town TH LEMA b.Authorized Signature 2/4/2011 d.Date(min/cid/my) ACCUTECH INSULATION( I.Representing PO BOX 376 01056 i.Zip Code Asbestos Notification Form•Page 3 of 3• 'N/A b.Project Monitor DOS Certification Number NIA b.Asbestos Analytical Lab DOS Certification Number 2122/2011 b.E nd Date(mml ddl yyyy) N/A d.Work hours Sat-Sun. nrtant: n filling out is on the puler,use the tab key ove your or-do not the return TRUCTIONS Commonwealth of Massachusetts Asbestos Notification Form ANF-001 1100120340 Decal Number A. Asbestos Abatement Description a.Is this facility fee exempt-city,town, district, municipal housing authority, owner-occupied residence of four units or less? GI Yes ❑No b.Provide blanket decal number if applicable: 2. Facility Location: 'HAMPSHIRE HEIGHTS - a.Name of Facility 'Northampton I MA C.City/Town d State 3. Worksite Location: MI sections of this n must be npleted in order mply with 4. P notification Irements of 310 IR 7.15 6' I the Division Occupational fety(DOS) ideation tuirements of 453 AR 0.12 'HAMPSHIRE HEIGHTS a.Building Name/Building Location 'BLDG 11 I b.Building U Is the facility occupied? Yes ❑No Asbestos Contractor: VA 1ACCUTECH INSULATION &CONTRACTING I a Name 'LUDLOW C.City/Town 1AC000005 DOS License Number 'JON HITE It Facility Contact Person 'JULIO VENTURA 6' a Name of On-Site Supervisor/Foreman 1N/A 7' a Name of Protect Monitor 01056 J d.Zip Code___ I 8. 1N/A a Name of Asbestos Analytical Lab 12/22/2011 O 9 a.Project Start Date mink! 1II O 7AM-4PM c.Work hours Mon-Fri. o 10 a What type of project is this? ❑Demolition 12 Renovation • ❑ Repair ❑Other, please specify: 11. a. Check abatement procedures: 0 0 LL 0 Glove bag ❑ Encapsulation LI Enclosure ❑Disposal only Cleanup ❑Other, specify: ❑Full containment 12. Is the job being conducted: J[,I Indoors? -J Outdoors? Blanket Decal Number 110 JACKSON STREET b.Street Address '01060 14015692277 e.Zip Code f Telephone Number c.Wing 1ST FLOOR' d.Floor 1APT'S A& D ' e.Room 1100 STATE STREET b Address 4135835500 e.Telephone Number g. Contract Type: J Written ❑Verbal Contact Persons Title 'AS001178 b.Supervisor/Foreman DOS Certification Number b Describe b.Describe IS anfoolap.doc•10/02 Asbestos Notification Form•Page 1 of 3 II Commonwealth of Massachusetts Asbestos Notification Form ANF-001 11100120340 Decal Number 0 0 01 A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or encapsulated' a.Total pipes or ducts(linear fl) c.Boiler.breaching,duct,tank surface coatings e.Corrugated or layered paper pipe insulation g.Spray-on fireproofing i.Cloths,woven fabrics k.Thermal,solid core pipe insulation 4 b. rota)other surfaces(square ft) J Lin.ft. Lin.M. Sq.ft L..J I Sq.ft.—. h Transite board,wall board Lin.ft. d.Insulating cement Sq.tt -I f.Trowel/Sprayer coatings Lin.ft. Lin ft. -I ).Other,please specify: u (VAT Sq.ft I.Specify 14. Describe the decontamination system(s)to be used: (SEAL CRITICALS W/6 MIL POLY,PRE-CLEAN, LAY DROP CLOTH& REMOVE USING THE NEC( Lin.ft Lin.ft Lie fl. L' ft Sq.ft Sq.N. 5� J 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): (ACM TO BE DOUBLE BAGGED/WRAPPED IN 6 MIL POLY& DELIVERED IN A SEALED VEHICL 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: J (N/A b.Title IN/A IN/A a Name of DEP Official c Date(mmtddlyyyy)of Authorization d.DEP Waiver p `N/A I 'N/A e.Name of DOS Official L DOS Official Title l (NIA h.DOS Waiver# g. Date(mMdd/yyyy)of Authorization 17. Do prevailing wage rates as per M.G.L. c. 149,§26, 27 or 27A—F apply to this project? []Yes❑No B. Facility Description 0 1 Current or prior use of facility 0 (RESIDENTIAL 2. Is the facility owner-occupied residential with 4 units or less? ❑Yes 7 149 OLD SOUTH STREET b.Address No 'NORTHAMPTON HOUSING AUTHORITY 1 I 01060 1 d.Zip Code 3' a.Facility Owner Name (NORTHAMPTON c.City/Town 4. JOHN CONNERS a.Name of Facility Owner's On-Site Manager (WARWICK 1,02886 c.City/Town d.Zip Code ■ anfootap.doc•10102 1413-584-4030 e.Telephone Number(area code and extension) 13600 WEST SHORE DRIVE b.On Site Manager Address _ 1401.569-2277 e.Telephone Number(area code and extension) Asbestos Notification Form.Page 2 of 3 El Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19000 0 Commonwealth of Massachusetts Asbestos Notification Form ANF-001 00120340 ■ Decal Number B. Facility Description (cont.) NATIONAL REFRIGERATION a.Name of General Contractor WARWICK c.City/Town 02886 1 d Zip Code AIG f Contractor's Workers Comp.Insurer 6. What is the size of this facility? 3600 WEST SHORE DRIVE b.Address 401-737-2000 e Telephone Number(area code and extension) WC5318622 g.Policy Number a.Square Feet 11/4/2011 h Exp Date(mm/dd/yyyy)� b Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site Of necessary). ACCUTECH INSULATION 8 CONTRACTING, I a.Name of Transporter LUDLOW c City/Town 01056 d.Zip Code 100 STATE ST. BLDG 119, PO BOX 376 b.Address 4135835500 e Telephone Number Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: J 110 NORTHWOOD DRIVE b Address RED TECHNOLOGIES a.Name of Transporter BLOOMFIELD c.Citv/Town 06002 d.Zip Code a.Refuse Transfer Station and Owner c.City/Town MINERVA ENTERPRISES INC a.Final Disposal Site Location Name 19000 MINERVA ROAD c.Final Disposal Site Address d.Zip Code J OH e.State D. Certification 44688 Zip Code The undersigned hereby states, under the p If fp rj ry th th / h h dth C Ith f M h n eg I f f th R I C t ' t Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15, and that the information ta' ed th's If C t dco e t t th bet fh' /h k Idg db I' f anf001ap doc•10102 8602182428 e Telephone Number b.Address e Tele hone Number b.Final Disposal Site Location Owner's Name WAYNESBURG d City/Town g.Telephone Number FAITH LEMAY N ADMIN ASSIST c Position/Title 4135835500 e Telephone Number 100 STATE ST. BLDG 119, ITH LEMA b.Authorized Signature 2/4/2011 d.Date lmm/dd/yryy) ACCUTECH INSULATION f.R resent PO BOX 376 q.Address LUDLOW h City/Town 01056 Zip Code Asbestos Notification Form•Page 3 of 3