78 Asbestos Notification Form 2001 Facility Deiraigtlon
1. Current or prior use of facility.
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2. Is the facilely owner-occupied residential with 4 units or less? 'Yes ❑ No
3 Facility Owner'.
CraMIL c-Cl.ax 2„ -1? W-05r S+,
Name AOOress
Nmr+har, pit n mA oio(o )1-∎1.) - 9 '
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4 Facility's Owners On-Site Manager.
0/A
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Itp mete Telephone
5 General Contractor:
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd .
Nme Address _.
Northfield MA . 01360 413 498-0201
ay/room bp code retepaone
Granite State Ins . Co. WC8540584 09/01/01
Contractor's WorkeR Comp.Insurer Polity I flw Dale
6. What is the size of the facility? :3•Ox60(sg ry) Q (/of floors)
9 Asbestos Transportation and Disposal
1. Transporter of asbestos-containing waste material from site to temporary storage site Of necessary)to final disp
Shearer & Snide Inc. dba/Ace Asbestos 716 Pine Meadow Rd .
Aherne Adll.ete
Northfield MA 01360 413 498-0201
crh/Imm tit.rare
Telephone
2 Transporter of asbestos containing waste material from removal/temporary storage site to final disposal site
Logano Trucking-Waste Mgmt 209 Pickering Street
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Portland CT 06480 860-342-0667
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Commonwealth of Massaciw
Asbestos Notification Form N BOARD OF HEALT
Asbestos Abatement Description
1 Facility location: �" :d
em o(2 id(-e e .cz
Name
NiryAown
78 k1(3# St
Address
wo r thGtmptoo in zam DloGO
ware
_D.LIV Y-Ovm
atu'is ilia w rIsIle 1x41011?Wilrlimmy rarm./wino.Iloo=,room
2. lc the tacinny occupied? gi Yes ❑ �•o
$ 5 - 5z4:-
rneplwne
1 Asbestos Contractor.
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd .
Mn.
Northfield MA .
Won,
AC000006
DU Lians?
4. On-Site Project Supervisor/Foreman:
Ed Shearer/Tom Shearer
Name
5. Project Monitor:
12 Name
Asbestos Analytical Lab:
EroJ iCr Or.%MtN P1L-..SRMOL-I,16
Nano \=-Sim, " OLIreNGCjfCn/ '.50
a� � i SaLSun1 nc
T Project start dated nu/�iend date 5r i 7/0/specific work hours(Mon:Fri.1 r ( update
A What tvoe of project is this? (circle one): amoelron reAVm
omerhMnl heat
Region
ns.
S(40
Aomesn
01360
do we
W( 4e-r,
Cwmv me Lw,imVro'Wl
413 498-0201
relepnme
AS70245, AS70066
OLI C&a Ijw/
Oil CeNllo4w/
f
Stations must
comp!y with the
Solid Waste
Division regula-
tions 310 CMR
18.00
Note:Contractor
must sign this
form for DLl
notification
purposes
3. Refuse transfer station and owner Of applicable)'.
N/A
Name Aaoress
Craown
4 Final Disposal Site'.
Valley Landfill
Ln axle Ielenlmoe
Waste Management/ Logano Tru
t MJlbn XXIV (Niters Nnne
Pleasant Valley Rd .
Antlers
Irwin PA 15642 724 744-7446
r_-. I•nan.
D
Certification •
The a;d-rsigned hereby states, undo the uecalt:es o! porury.!hat he/she has read the Commonwealth o1 Mzss?chircntc
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 his/her knowledge and belief.
Ef4, rd ? Shearer e919 ,v ,,SHL:
mile Name AufliNM 5undure Dale
1I Shearer & Snide Inc. dba/
('PS IU'0ilt Ace Asbestos Removal 413 4
nosihOOAlie
716 Pine Meadow Rd .
Atles5
renter nlrnu relegMne
Northfield , MA. 01360
LI%MIe
Fee exempt(City,Town,district, municipal housing authority,owner-occupied residential of four units or less)?Y3
Sticker I(from front of form): 7 J (3 2,0
i
by oucui
9. Describe the asbestos abatement procedures to be used (circle): glove gay embsure mmm�lanoxnr ) oenw
set—up variable air pressure,
erensmaim tisrysNOUlr omerivepml poly work area,HEPA vac , HEPA
filter respirator , wet asbestos
10. Is the lob being conducted s indoors ❑outdoors ?
11. Total amount of each type of Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear R.) / 5 or other
surfaces(square ft.) 11C to be removed, enclosed or encapsulated:
linear/square feet
boiler.breaching,duct lank surface coatings. / 40 thermal,sold core pipe naulation
corrugated or bawd paper pipe insubtion._. I / ins4a!Ng camelW —J--
spray-on fireproofing / Uawel/sp']ly coatings...
dada,woven bbria / Yansile bond,wall board —-/—
other(please describe/ _J
12. Describe the decontaminatior,system(s)to be used.
3 chamber decors unit w/warm water
shower , tyvelm 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)(9)
Pewet asbestos & oack 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:
Mine oar perul
Ora asurnovaoa
an ant)a/wl
Oat W/u:bowsaw)
Fine
15. Do prevailing wage rates apply as per M.G.L.c 149,§26, 27.or 27A-F to this project? ❑Ye
No