4 Asbestos Notification Form 1999 D Facility Description
1. Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or less? XI Yes C No
3. Facility Owner:
or■ ai.Lcsk 4 'Bar rtif
None Address
100.6-hampte-n in A. 10.60 ('113) 58b- oS1
Ciry/Toon Zip woe Telephone
4. Facility's Owner's On-Site Manager.
4•5 i A
Cily/Toom Zip rode Telephorw
5. General Contractor:
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd.
Name Address
Northfield MA. - 01360 413 498-0201
City/low DO code 1 04_coy Telephone
Granite State Ins. Co. WC 3515462 00 03/01/98 9)2 )99
Con:me:ors Workers Comp Insurer Policy 1 Exp.Oate •
6, What is the size of the facility?36 4,0(sci ft)_2_(#of floors)
113 Asbestos Transportation and Disposal
1. Transporter of asbestos-containing waste material from site to temporary storage site(if necessary)to final disposal site:
Shearer & Snide Inc. dba/Ace Asbestos 716 Pine Meadow Rd .
Address
Northfield MA 01360 413 498-0201
CVIOwn bp rode Telephone
2. Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site:
same as above
Name Adafebb
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PPR ' 8 1999- --
Commonwealth of Massachusetts
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Asbestos Notification Form— ANF-001 - : P- •-•ffi -0 I
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13 Asbestos Abatement Description
;
\,>:•-•-..-2.'' 1. Facility location:
liki4irS k Ces idehn et 1.1 3 oY-r e,k-E. Fl ace_
IIISTRUCTIONS Name Address
1.All sectors al this NI\e,(*kara?fon InA 0 10(p0 +5 52(0- 105r1
Norm must be completed Ciry/rom IM rode lidepAone
in ceder tocompy wit baU.-018,7nt
Pm 110133011011111 01
M,4 is Me AMUi fralmn?budding narle.A wing do&loom
Environmental
"ctim mtheatmn
requirementsid TIO CAC 2. Is the facility occupied? N Yes 0 No
715 (ten workers days
pnor noldtahon s 3. Asbestos Contractor:
reqQaddanY"ems Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Pd .
project andthe
Department of Labor Pone As
end thdestries Northfield MA. 01360 413 498-0201
notification requirements
o1453CMR612 (len Guy/Tow bp axle deepen.
days pnot nallication a
mewed al ANY AC000006 LOYIE18/11\
abalemeal pioject pieta DV tame/ Coto rten(wrdierWerbat)
than Three loam or
Ware k et 4. On-Site Project Supervisor/Foreman:
2 theme Original Form Ed Shearer/Torn Shearer AS70245, AS70066
To: mane 01.1 Cenderahun I
Commonwealth al
Massebusetts 5. Project Monitor:
Asbestos Program
P.0.11.120087
Bruton,MA 021* Name DU Centhcatod I
0087
6. Asbestos Analytical Lab.
3 This Ism may be ,., • ,
used fru[whim the Efj1/41(2Q f■Y\EASIT4(._ SAMetimG & AA000 I 31
U.S.Enwavnentai Name -rIST(MG al Cellitalwn I
Protection Acency Region 036 L/30
I ol asbestosdemolition/ 7. Projectstartdate03/A Vend date03/24/9ispeciticworkhours(Mon.-Fri.) a Cl- p (Sat.Sun.) ft'lll
renovation°mations upd a
subpd to NESiii1P500
cFft 51.111Pe!t.Ill9 8. What type of project is this? (circle one): demolition mpw„inCThh„ opier(w(n) heat
— syst
Note:Transfer cifIuwn bp rule riterdere
Stations must 3. Refuse transfer station and owner Of applicable):
campy with the
Solid Waste N/A
Division regula- Nan. Address
Bons 310 CMR
18.00
Note:Contractor
must sign this
form for DV
notification
purposes
ciry/rppi Im rule telephone
4. Final Disposal Site:
Valie Lhd1iI
Lx4a Nine nj
?f.w.s an Vto Ra
11-26,31N 7A
ISC Hi (/w4) 7(1v-7+4G
bh code Tory IhOnP
D
Certification •
The undersigned hereby states,under the Pena."ties of perjury,that he/she has read the Commonwealth of Massachusetts R
for the Removal Containment or Encapsulation of Asbestos,453 CMR 6.00 and 310 CMR 7.15.and that the information a
this notification is true and correct to the best of his/her knowledge and belief.
5dRXtat D Shearer
Printlia e
Pres:du-t
{1nYlwnide
AMn'Ved Si nfur owe
Shearer & Snide Inc. dba/
Ace Asbestos Removal 413 49
a) ate./9
716 Pine Meadow Rd.
iiepeYntig TelegWe
Northfield, MA. 01360
Address eifr/rwni hp oxk
Fee exempt(City.Town.district,municipal housing authority,owner-occupied residential of four units or less)?NI
Sticker l(from 7 rom front of form): /'I 6 r r�
9. Describe the asbestos abatement procedures to be used (circle): gloaiDag enclosure luarmamrenl clenm
=claim msl[sawq oatquptin) set—up variable air pressure,
poly work area,HEPA vac,HEPA
filter respirator,wet asbestos
10. Is the job being conducted fq indoors O outdoors?
11. Total amount of each type of Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear ft.) c 0 or ether
surfaces(square It.) no to be removed,enclosed or encapsulated:
linear/square feet
boiler.breaching,dub,tank surface coatings.__/ bmmat sold core pipe'obviation
=Maid w bendpapw ppe insulation....$QQ/ Subbing cement
spay-on kW=fob —/ 0welhpaler coatings
cloths,woven fabrics J brine board,wall board J
Ow(pease describe)
12. Describe the decontamination system(s)to be used: 3 chamber decon unit w/warm water
shower,tyvelc suits,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 officials who evaluated the emergency:
Mn of DEP Offcial
Dale daub aun
Named DU Cllcal
Data hllWakw
nee
ewer/
!le
Warner/
15. Do prevailing wage rates apply as per M.G.L.c.149.§25.27,or 27A-F to this project? ❑Yes X No