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:TRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100157196
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:
'NORTHAMPTON STATE HOSPITAL
a.Name of Facility
NORTHAMPTON
c.city/Town
3. Worksite Location:
VILLAGE HILL ROAD
VI sections of this
must De a.Building Name/Building Location
npleted in order
;ompry vnth
P notification
r ems of 310
IR7.15 5.
I the Division
Occupational
tety(DOS)
it-cation
luirements of 453
IR612
MA
d.State
12
b.Building#
4. Is the facility occupied? ❑Yes ❑No
0
6.
7.
8.
Asbestos Contractor:
ENVIROGREEN LLC
a.Name
BOSTON
c.City/Town
IAC000749
02130
d Zip Code
f.DOS License Number
h.Facility Contact Person
FRANKLIN HERNANDEZ
a.Name of On-Site Supervisor/Foreman
Blanket Decal Number
'VILLAGE HILL ROAD
b Street Address
01060
N/A
a.Name of Project Monitor
N/A
a Name of Asbestos Analytical Lab
9/11/2012
9' a.Project Start Date(mm/ddlyyyy)
e.Zip Code
c.Win
f.Telephone Number
d.Floor e.Room
81 CHESTNUT AVE
b.Address
8578913842
e.Telephone Number
g. Contract Type: ❑Written
❑Verbal
Contact Person's Title
AS061855
b.Supervisor/Foreman DOS Certification Number
IN/A
Project Monitor DOS Certification Number
N/A
o '7:00-3:30
c.Work hours Mon-Fri.
b.Asbestos Analytical Lab DOS Certification Number
9/25/2012
b.End Date(mmlddlyyyy)
10 a What type of project is this?
0 f4 Demolition ❑ Renovation
❑ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
0
0
U-
z
0
Glove bag
❑ Enclosure
❑ Cleanup
Full containment
0
❑ Encapsulation
❑ Disposal only
LT, Other, specify:
d.Work hours Sat-Sun.
b.Describe
WHOLE COMPONENT
b.Describe
12. Is the job being conducted: V Indoors? C Outdoors?
anf001 ap doe•10/02
Asbestos Notification Form•Page 1 of 3
Commonwealth of Massachusetts
r
Asbestos Notification Form ANF-001
•
(100157196
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed,or
encapsulated:
1.2350 f 1120
a-Total pipes or ducts(linear b. total other surfaces(square
c.Boiler,breaching,duct tank I 1 d.Insulating cement
surface coatings Lin.ft. Sq.ft.
e.Corrugated or layered paper :550
pipe insulation
g Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
Lin.ft. Sq.ft. f Trowel/Sprayer coatings
. F
Lin ft.
Lin ft
Lin..fl.
h.Transite board,wall board
Sq.ft
Sq.fl. I.Other,please specify:
ICLK/FLR.
Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used:
Lin.ft.
Lin.ft
Lin.ft.
11800
Lin.ft.
Sq ft
Sq.ft.
1120
Sq.ft.
I3 STAGE DECONTAMINATION UNIT
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
16 MIL DOUBLE BAGGED,WETTED AND LABELED FOR TRANSPORT
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a.Name of DEP Official
nle
yyy
c Date(mm/ddly)of Authorization
d.DEP Waiver if
e.Name of DOS Official f.DOS Cffkial Title
g.Date(mm/dd/yyyy)of Authorization 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? 7 Yes Z''No
o B. Facility Description
o 1. Current or prior use of facility:
=o
HOSPITAL
2. Is the facility owner-occupied residential with 4 units or less? j Yes No
No
3 CITY OF NORTHAMPTON 1
a.Facility Owner Name b.Address
° 1
c.City/Town d.Zip Code _ e.Telephone Number(area code and extension)
1
4' a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address
I
z
C c.City/Town d Zip Code
I anf001apdoc•10/02
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3 U
l Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
te:Transfer
dons must
nply with the
lid Waste
ision
gulations 310
IR 19.000
100157196
Decal Number
B. Facility Description (cant.)
a.Name of General Contractor
c.City/Town
f.Contractors Workers Comp.Insurer
6. What is the size of this facility?
d.Zip Code
b.Address
e.Telephone Number(area code and extension)
y_Policy Number h.Exp.Date(mnvdd/
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):
a.Name of Transporter
c.City/Town
d Zip Code
∎
b.Address
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
':SERVICE TRANSPORT GROUP
a.Name of Transporter
1 NEW CASTLE
c.City/Town
3.
4.
■19720
d Zip Code
a.Refuse Transfer Station and Owner
c.City/Town d.Zp Code
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
MINERVA ROAD
c.Final Disposal Site Address
OH � 44688
e State f.Zip Code
58 PYLES LANE
b Address
8779999559
e.Telephone Number
b.Address
e.Telephone Number
b.Final
Disposal Site Location Owner's Name
'WAYNESBURG
d.City/Town
g.Telephone Number
° D. Certification
0
°
LL
2
The undersigned hereby states, under the
p It fpej ry,thth / h h dth
C ealth f M h tt g I t
for the Removal, Containment or
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR T15, and that the information
t fined in this notification is true and correct
to the best of his/her knowledge and belief
anf001ap doc•10/02
LOUIS JAVIER
a.Name
PRESIDENT
c Position/Title
.8578913842
e.Telephone Number
81 CHESTNUT AVENUE
q Address
JAMAICA PLAIN__
h.City/Town
LOUIS JAVIER _
b.Authorized Signature
8/2812012
d Date(mm/dd/yyyy)
ENVIROGREEN LLC
f.Representing
02130
Zip Code
Asbestos Notification Form•Page 3 of 3