70 Asbestos Notification Form 1999 — anS1051
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EFT;Wity Description
1. Current or prior use of facility
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2. Is the facility owner-occupied residential with 4 units or less? Yes 0 No
3. Facility Owner:
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Mn Address
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4. Facility's Owner's On-Site Manager:
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5. General Contractor:
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd.
Name
Northfield MA.
moron
01360 413 498-0201
coeftom zeave redeem.
Granite State Ins. Co. WC 3515762 00 09/01/99
Contractor's Workers Comp Insurer Poky,' fig,Date
6. What is the size of the facility?.3e/Vo(so ft) - -(#01 floors)
Asbestos Transportation and Disposal
1. Transporter of asbestos-containing waste material from site to temporary storage site(if necessary)to final disposal site:
Shearer E. Snide Inc. dba/Ace Asbestos 716 Pine Meadow Rd.
tam kerress
Northfield MA 01360 413 498-0201
nwroim &rah Wohom
2. Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site:
same as above
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5. General Contractor:
Shearer & Snide Inc dba/Ace Asbestos 716 Pine. Meadow Rd.
Mime Maws
Northfield MA. 01360 413 498-0201
GNACm ZiOCOGe Teliplone
Granite State Ins. Co. WC 3515762 00 09/01/99
Contractor's Workers Comp Insurer / Poky/ bpO)le
6. What is the size of the facility?.%LX Vd(sq ft) (t of floors)
0 Asbestos Transportation and Disposal
1. Transporter of asbestos-containing waste material from site to temporary storage site(it necessary)to final disposal sit
Shearer & Snide Inca dba/Ace Asbestos _716 Pine Meadow Pd.fWUeagnS
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Note:Transfer Clfrii01.11 ZIP axle le leNtone
Stations must
3. Refuse transfer station and owner(if applicable):
campy with the
Solid Waste N/A
Division repute- Nime MOM
Pons 310 CMR
18.00
Note:Contractor
must sign this
form for MI
notification
purposes
Cay/Town Tele/ewe
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4. Final Disposal Site:
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Tft_ascur14 V(u-,(11 Rd
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7744 - 7L
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Certification .
The undersigned hereby states,under the penalties of perjury,that he/she has read the Commonwealth of Massachusetts F
for the Removal.Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15.and that the information ci
this notification is true and correct to the tint nf hiske!I/mewled:251nd bxficf.
Pm,Name
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Shearer & Snide Inc.
Ace Asbestos Removal
716 Pine Meadow Rd.
RePtesenAl
Northfield, MA.
Telephone
01360
Adaress Cifloirri • ZIP cads
Fee exempt(City,Town,district,municipal housing authority,owner-occupied residential of four units or less)7/4
Slicker!(from front of form): 7 3/5 '76
9. Describe the asbestos abatement procedures to be used (circle).a(circle). enclosure luncontain Sri
set—up variab e air pressure,
eeawaauo diurnal only omw(mpvn) poly work a rea,HEPA vac,HEPA• filter respirator,wet asbestos
10. Is the job being conducted K indoors ❑outdoors? J�1
11. Total amount of each type of Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear ft.) P/0 or other
surfaces(square ft.) — to be removed,enclosed or encapsulated:
linear/square feet
bode,breaching.dud,tank surface coatings . IMlmal,solid ore pipe iisulation
corrugated Of kyvropappope inwknon. insulting cement _J
spay-on fireproofing _1 tewetspays coatings
cloths,worm Winos _/ tusk board,on bond
of (pease decibe) _/
12. Describe the decontamination system(s)to be used.
3 chamber decor unit w/warm water
shower ,tyvelc su its,HEPA vac for clean—up. _....
13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g):
Rewet asbestos & pack in labeled double sealed poly bags
before removal from site. -
14. For Emergency Asbestos Abatement Operations,the DEP and DLI ofticoh MID evaluated the emergency:
Nine oIDEPoeeie
Oat aAamiann
Name call pknl
Dal ahllWJlen
title
Waxy/
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15. Do prevailing wage rates apply as per M.G.L.c.149,§26,27.or 27A-F to this project? ❑Yes XI No