324 Asbestos Notification Form 1999 . _
•
Facility Description
1. Current or prior use of facility:
RESIDENCE
2. Is the facility owner-occupied residential with 4 units or less? .$,Yes 0 No
3. Facility Owner:
nAgy 5s2"/ .Be/DG e_ sc
Mn m."
NoR-thamP
o1040 0113) ,52 -0103
cerwrown zip rale Telephone
4. Facility's Owners On-Sue Manager:
Mn MWess
Cilylloom lip rale Teleonone
5. General Contractor:
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd.
Name Address
Northfield MA. - 01360 413 498-0201
a&404.7 /Pcweiliino_Sirecg_ Telephone 11 q
Granite State Ins . Co. WC -381D7rz—U0 —091-047148
Contmclor's Workers Comp Insure! Poky) Exp Date
6. What is the size of the facility? SO x toe(so II) (tot floors)
laAsbestos 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 .
Mn moms
Northfield MA 01360 413 498-0201
Cily/lovm Zip wit telephone
2. Transporter of asbestos-containing waste material from removal!temporary storage site to final disposal site:
same as above
him* Addles)
Now
AN, Commonwealth of Massachusetts ' MAR 5 190 ,
--- - . _„,,-,,,,n,n ,
Asbestos Notification Form — ANF-0014e.la/ d -; .? ti-44:oi 0 '
1,.-1)- 7.-
- ''nr‘ )r7 . 4'.2' ! 1-e:f5: CM-rTh\
13
Asbestos Abatement Description
\- 1. Facility location:
.._ ,
Flirts r-451 dente_ 3,24/ 5gloce ,3'1,
•STUUCTMAS Name AddraS5
1. All sections piths gOtarRA Pi Pip 4.) /44 0/060 V/3 ,52 -01O3
tam must be completed cityfi°'" no axle anemone
m order to comply with
ha
t 5eer .t.
he Deportment of M ).
Environmental moo me gentile demean buoduc,an . coo boo nom
Protection soSfication 2. Is the facility occupied? 11/4 Yes 0 No
requirements oI310 CMR
7.15 ((en costing dayS
poor nolif cam a 3. Asbestos Contractor:
Wund°40"7" Shearer 6, Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd .
miemtamMe
Department of Labor Name Address
and Industries
Northfield MA. 01360 4 1 3 4 9 8-0 2 01
Dalmatian Inurement°
o1453 CMR 612 (ten adynorm Ito ace Teepee.
days poor notolcabon a
terperectot ANY A0000006
6,Jr/ II
abatement prated'paten
al license I
0 817,11 Gatti Ine(ennetureCa)
W Meat al
sauce Nen 4. On-Site Project Supervisor/Foreman:
2 Submit Original Form Ed Shearer/Tom Shearer AS70245, AS70066
To: NM. Dli Gemination/
Commonwealth of
Massachusetts 5, Project Monitor:
Asbutes Program
P.03.120087
Itstoe,MA 02112- MOO al Cerftkall0411
0087
6. Asbestos Analytical Lab
3 This form may be
used tor nottlfing the (4)ili‘OAFEA-12-19L 4.5-/F7(1/904.)6:,,,,g
U.S Envuonmental acme yjis 17A.(o- 00 COMficalion 1
Protection Acety Flemon
93d ej qn)
igiagbeggsdemgimon, 7. Projectstart date 43//SI/?9end date 48/4 9Vspecific workhours(Mon.-Fri.) 0 ar /-it (Sat.Sun.)- flc
movation orations
Up d z
stibteM to NEAPS(40
CFR Subpart MI 8. What type of project is this? (circle one): aemolmon new ren( oTa--)Itoo opp,feyNe,pe heat
Noh:Transfer Clf/lowr Zip rale telephone
Stations must. 3. Refuse transfer station and owner Of applicable):
comply with the
Solid Waste N/A
Division regula- xane
lions 310 CMR A0°""
18.00
Note:Contractor
must sign this
form for Dll
notification
purposes
Crtno.,r
Zip rode Telephone
4. Final Disposal Site:
kS e ryl� nV ti)f1 R uo cOk_664 l d6 (
tmaGUas Gowan
t
/2/WS a-nfi VrrL i?c�.
-a—kw IN PA
Ciavtam
( S(C4Z (,14) -744 r»
Zia code
D
Certification
The undersigned hereby states.under the penalties of perjury.that he/she has read the Commonwealth of Massachusetts
for the Removal.Containment or Encapsulation of Asbestos.453 CMR 6.00 and 310 CMR 7.15,and that the information
this notification is true and correct to the best of hisiher knowledge and belief.
Edward D. Shearer c 313119
Grml Mane Autirwq L9neure Ode
r�
Shearer & Snide Inc. dba/
Pc.es d ent Ace Asbestos Removal 413 4'
P avlae alywo ong iaeptwe
716 Pine Meadow Rd.
Northfield, MA. 01360
Address City/town A aide
Fee exempt(City.Town,district, 3 municipal 96
l housing authority,owner-occupied residential of four units or less)
Sticker a(from front of form): 7 I l l 68
ea
9. Describe the asbestos abatement procedures to be used (circle): yore tag ercmsme e.Rt�j aea,w, y•.'
set—up variable air pressure,
poly work area ,HEPA vac,HEPA
filter respirator,wet asbestos
exammaun
[Mama/ 1/
nbertarpaln)
10. Is the job being conducted A indoors ❑outdoors?
11. Total amount of each type of Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear ft).7g00 pyothH
surfaces(square ft.) 4i8 to be removed,enclosed or encapsulated:
linear/square feet
bolko.breachlrg,duct.tank surface coatings / H8
rornrpnEd a,6/erNpapwpipemsofnono'Ja?2/
spay-on fireproofing
Mts.womn kbrts
odn(ukase describe)
J
J
J
12. Describe the decontamination system(s)to be used:
shower,tyvek- suits,HEPA vac for clean—up.
thermal,sold care pipe insulation
imam cement
howUyrayer coatings
harms board,nil board
J
J
J
J
3 chamber decon unit w/warm water
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 bays
before removal from site.
1t For Emergency Asbestos Abatement Operations,the DEP and DLI officials who evaluated the emergency:
Name NOM Vocal
me
oavInotwalon
Nam ad Moat
INN of Aulhowe rn
Water/
15. Do prevailing wage rates apply as per M.G.L.c.149.§26.27,or 27A-F to this project? ❑Yes No