7 Asbestos Notification Form Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100204499
Asbestos Project#
I— Project Revision
r Project Cancellation
Instructions 1.All
sections of this form
must be completed in
order to comply with
MassDEP notification
requirements of 310
GMR 7.15 and
Department of Labor
Standards(DLS)
notification
requirements of 453
CMR 6.12
MassDEP Use Only
Date Received
2.Submit Onginal
Form To
Commonwealth of 6.Asbestos Contractor:
Massachusetts NEWENGLAND SURFACEWINTENANCE
Asbestos Program
P.O.Box 120087
Boston,MA 02112-
0087
A. Asbestos Abatement Description
I.Facility Location:
MONTGOMERY HOUSE
NIVannlinstseumnin
Name of Facility
NCRTNMPTON
City/Town
XXX
Street Address
MA 01060
0000000000
State Zip Code Telephone
xxx
Facility Contact Person Name
Facility Contact Person Title
Worksite Location: LOADING DOCK
Building Name,Wing,Floor.Room,etc.
2. Is the facility occupied? F Yes r No
3. Is this a fee exempt notification (city,town, district, municipal housing authority, state facility, or
owner-occupied residential property of four units or less)? F Yes F No
4.Blanket Permit Project Approval,if applicable:
Approval ID#
5.Non-Traditional Asbestos Abatement Work Practice Approval,
if applicable: Approval ID#
Name
WEYMOUTH
850 WASHINGTON STREET
Address
MA 02189
7813372117
City/Town
AC000196
State Zip Code Telephone
Contract Type: F written r Verbal
DLS License#
7, KENNETH M FURTNEY ASO40208
8
9,
Name of Contractor's On-Site Supervisor/Foreman
Name of Project Monitor
DLS Certification#
N/A
DLS Certification#
N/A
Name of Asbestos Analytical Lab DLS Certification#
10. 8/132014 8/13/2014
Project Start Date(MM/DDAVYY) End Date(MMIDDMIVV)
8-4 N/A
Work Hours-Monday Through Friday
I I.What type of project is this?
r Demolition F Renovation r Repair r Other- Please Specify:
Work Hours-Saturday&Sunday
Revised:11/13,2013 Page I of4
tra
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100204499
Asbestos Project#
Project Revision
r Project Cancellation
A.Asbestos Abatement Description: (coot.)
12.Abatement procedures(check all that apply):
✓ Glove Bag r Encapsulation r Enclosure F Disposal Only r Cleanup r Full Containment
✓ Other-Please Specify:
13.Job is being conducted: F Indoors r Outdoors
14.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:
Linear Feet(Lin.Ft)
Boiler.Breaching,Duct,
Tank Surface Coatings
Pipe Insulation
Spray-On Fireproofing
Cloths, Woven Fabrics
Insulating Cement
Lin.Ft.
Sq.Ft
Lin.Ft.
Sq.Ft
Lin.Ft. Sq.Ft
Lin.Ft. Sq.Ft.
Lin.Ft. Sq.Ft.
15.Describe the decontamination system(s)to be used:
AS REQUIRED
294
Square Feet(Sq.Ft.)
Transite Pipe
Transite Shingles
Transite Panels
Other-Please Specify:
Lin.Ft 5q.Ft
Lin.Ft Sq.Ft
Lin.Ft Sq.Ft
DOORS 294
Lin.Ft Sq.Ft
16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g):
AS REQUIRED
17.For Emergency Asbestos Operations.the MassDEP and MS officials who evaluated the emergency:
Name of MassDEP Official Title of MassDEP Official
Date of Authorization(MM/DDNYYY) Waiver ft
Name of DLS Official Title of DLS Official
Date of Authorization(MM/DD/YYYY) Waiver
18.Do prevailing wage rates as per M.G.L.c. 149, §26,27 or 27A—F apply to this
project?
r Yes r No
Revised: 11/13/2013
Page 2 of 4
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100204499
Asbestos Project#
✓ Project Revision
✓ Project Cancellation
B. Facility Description
I.Current or prior use of facility: SPECIAL NEEDS FACILITY
2. Is the facility owner-occupied residential with 4 units or less?
3,MONTGOMERY HOUSE ]POMERO TER.
Facility Owner Name Address
NORTHAMPTON MA 01060
City/Town State Zip Code
4.XXX XX
Name of Facility Owners On-Site Manager Address
NORTHAMPTON MA 01060
State Zip Code
City/Town
S,XXX
Name of General Contractor
NORTHAMPTON
City/Town
Note:Temporary X
XXX
r Yes FNc
0000000000
Telephone
0000000000
Telephone
Address
MA 01060
0000000000
State Zip Code Telephone
storage of Asbestos Contractors Workers Compensation Insurer 1/1/2015 waste
material is only X Expiration Date(MMIDO/VYYV)
allowed at the place Policy#
of business of a[XS 3000 2
licensed Asbestos 6.What is the size of this facility.
contractor or a transfer
station that is Square Feet #of Floors
permitted by
MassDEP and C. Asbestos Transportation & Disposal
opepliance with solid
in
waste Regulations I.Transporter of asbestos-containing waste material from site of generation:
CMR 19.000
r Directly to Landfill or r To Temporary Storage Location/Transfer Station
NEW ENGLAND SURFACE MAINTENANCE,LLP
850 WASHINGTON STREET
Name of Transporter Address
WEYMOUTH MA 02189
State Zip Code Telephone
7813372117
City/Town
2.If temporary storage location/transfer station is used,list name of transporter of asbestos containing
waste material from temporary storage location/transfer station to final disposal site:
RED TECHNOLOGIES
Name of Transporter Address
BLOOMFIELD
Cr 06002 0000000000
City/Town State Zip Code Telephone
10 NORTHWOOD DRIVE
Revised: I 1/13/2013
Page 3 of 4
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100204499
Asbestos Project#
✓ Project Revision
✓ Project Cancellation
to:comraaor mast C.Asbestos Transportation& Disposal: (cant.)
gn this form for DL5
tincation pumoses 3.Name and address of temporary storage location/transfer station for the asbestos containing waste
material.
203%GKERINGSTREET
REOTECHNOLOGIES
Address
PORTLAND Storage Location Name 0000000000
PORTLAND Cr 06480
State Zip Code Telephone
City/Town
4 Name and location of final disposal site(asbestos landfill):
MINERVA
MINERVA ENTERPRISES
Final Disposal Site Owner Name
Final Disposal Site Name
9000 MINERVA ROAD
Address 44688 0000000000
V6AYNESBURG CH
State Zip Code Telephone
city/Town
D. Certification
"I certify that I have personally
examined the foregoing and am
familiar with the information
contained in this document and
all attachments and that,based
on my inquiry of those
individuals immediately
responsible for obtaining the
information,I believe that the
information is true,accurate,and
complete.I am aware that there
are significant penalties for
submitting false information.
including possible fines and
imprisonment.The undersigned
hereby states.under the
penalties of perjury,that I have
read the Commonwealth of
Massachusetts regulations
governing asbestos abatement
(453 CMR 6.00 promulgated by
the Department of Labor
Standards and 310 CMR 7.15
promulgated by the Department
of Environmental Protection),
and that I am aware that this
permit application or notification
shall not be deemed valid
unless payment of the
applicable fee is made."
Revised: 11/13/2013
KEN FURTNEY KEN FURTNEY
Authorized Signature
R:
PA 7/30/2014
PARTNER
Date(MMfDOM"Y1)
7813372117 NESM'LLP
Telephone Representing
850 WASHINGTON WASHINGTON STREET GEYMO1NH
Address City/Town
MA 02189
Zip Code
State
Page 4 of 4