15 Asbestos Notification Form 1999 El Facility Description
1. Current or prior use of facilAV:
•
2. Is the facility owner-occupied residential with 4 units or less? ;It Yes 0 No
3. Facility Owner:
Sek.ilk1ar..1-Z J Detct sk Ct.
Name Mares:
e AMP-Th13 M 0 1060 (24 I 3) 58Y- 905 ,
bp rale telephone
Cily/T Pam
4. Facility's Owners On-Site Manager:
N/A
•
ClN/Tolln lip race amphora
. General Contrnter:
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd.
Name Adams
Northfield MA. . 01360 413 498-0201
ciwrom Zip code sail_io ti,e. y Telephone q 9
Granite State Ins . Co. WC Jr-5762—A 09/01/98
Contractors workers Comp Insurer Poky I &ANN
6. What is the size of the facility?3Ger 90(sq ft) a (i of floors)
121 Asbestos Transportation and Disposal
1. Transporter of asbestos-containing waste matetht from site to temporary storage site (if necessary)to final disposal site:
Shearer & Snide Inc. dba/Ace Asbestos 716 Pine Meadow Rd.
Name Address
Northfield MA 01360 413 498-0201
wow! zipayk reerknot
2. Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site:
same as above
Nine Athfre.”
1 w wmal,,, Commonwealth of Massachusetts
• r 7_ Asbestos Notification Form— ANF•001 ! 7711426 1
is' _ <.
0 Asbestos Abatement Description
\� 1. Facility location:
Sch ,�ar•tz _residence_ 15 )e .1c.A� C7-t, .
INSTRUCTIONS Nam Address
t. All sectors completed orm r��R�^n 4'f'q .1 1A O..I.'atop C5 Sg`)
-c,
brm roust wmDleled Gri/TUrsrl Ln r - v
m order to comply wim J -t r r- s --
the(n Oepadment of MN a nor wabae 1p'>mn?IM ayon I wing,flow room
Environmental FEB 16
Protection notification 2. Is the facility occupied? dyes 0 N
requirements x1310 GM
715 IOM waking days ----
prat natation s
Munadoranyabatement Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow .R4—
pro/M:and the
Department of Labor wane Maras
and Industries Northfield MA . 01360 413 498-02(
notification regurre(ten6
ofa53CMn6.12 Uen Cirynam Zip one Telepmne
days c/Atthcalims
reguveded MANY AC000006 Wrtiier\
abalemstmewl greater al(tamer Caetr Tyre(wrilnhaov)
Van tine Imam
Sore/ae4. 4. On-SNe Project Supervisor/Foreman:
2. SUbmrt Original Earn Ed Shearer/Tom Shearer AS70245 , AS70066
To Nora N(ICedrahool
Commoemoalth of
Maaachu efts 5. Project Mondor:
Asbestos Program
P.0.1.120067 _.
Boston,MA02112- NNm (Xi cer/Imam/
0087
6. Asbestos Analytical Lab.
3. This lorm maybe �1
used car nmidng be Skit(rROJ Mealy 1- shNipLa3C g AA 000 )32
U S.Enwuonmemal Nine 'e5 f f t3G- Old retir anu,a �'y
Praedion Agency Region �y3 Dr 99 D3 6 '�� q3/
(Sat.of asbemos dmnolRbnl 7. Project start dat /_/_end date / /99speciicworkhours(Mon-Fri) a- P(Sat.Sun.).
renovation operations
CFRSutoartM) SIOU 8 What type of project is this? (circle one): demourron rear reovNWn meraxpain)
CFRSubpal Ml.
Nola: Tnusicr
Stations must
cornpty with the
Solid Waste
Division regula-
tions 310 CMR
18.00
Note:Contractor
must sign this
form torn()
notification
purposes
3. Refuse transfer station and owner(if applicable):
N/A
Mn
CiryAwn
d. Final Disposal Site:
Uaii j Landfill
Me
heasan1 Valley 4
l,eitl i,J PA
Adaess
lip code releporie
/r1.43-T£ /%%cot e
[Westin
/56'{2
I:code
/LO(gjtJC
7720 Ck rn:
25' 7cq - 7519
TMrryp,v
D
Certification •
The undersigned hereby states.under the penahies of perjury.that he/she has read the Commonwealth of Massachuse
ter the Removal.Containment or Encapsulation ef Asbestos, 133 CMR 5.00 and 310 CMR 7.15.and that the inlormatu
this notification is true and correct to the best of his/ner knowledge and belief.
rcegie rot b, ,.Attarer
Nql Man
?re$t`d.&n t
e Ce/111,
Auare151pnare aft
Shearer & Snide Inc. dba/
Ace Asbestos Removal 413
716 Pine Meadow Rd.
FkOmaNtilp lepton
Northfield, MA. 01360
Addtas
Cly/rwn Londe
Fee exempt(City,Town,district,municipal
ho/usin�g/authority,owner-occupied residential of four units or less)?;
Slicker I(from front of form): 73 /Ti
9. Describe the asbestos abatement procedures to be used (circle): yore um wawa wl rotannfo demi
set-up variable air pressure,
saysmaan GiSp054 wit omerte<Maml poly work area,HEPA vac,HEPA-
filter respirator,wet asbestos
10. Is the job being conducted indoor ❑outdoors?
11. Total amount of each type of Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear tt.)/8/0 ormher
surfaces(square ft.) to be removed,enclosed or encapsulated:
linear/square feet
boils.Preaching,duct tank surface coatings_. / thermal,said core pipe insulation
corrugated or lamed paper ace insulation..../f,G/ inwWngmmmnt _J
spray-on fireproofing / taeetspam coatings
cblhs woven pbrics tensile board well board _l-
ather(please describe) _J
12. Describe the decontamination system(s)to be used
shower,tyvek- suits,HEPA vac for clean-up.
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 bags
before removal from site.
14. For Emergency Asbestos Abatement Operations,the DEP and DLI officials who evaluated the emergency:
wne dNP may roe
DO 0MMUMtaim Wales
Rancoml Odra;
We tlhItIo lakm warn
15. Do prevailing wage rates apply as per M.G.L.c.149,§26,27,or 27A-F to this project? ❑Yes )4 No