296 Asbestos Notification Form 2000 facility Dascription
t. Current or prior use of facility:
R�sfpwce
2. Is the facility owner-occupied residential with 4 units or less? )2I Yes 0 No
3 Facility Owner:
Li i S-lawe - Ihorsfan a9G `3Rf Rot
vane
CCe<nce. 1 A 0/06,„Q _sEta - 19,7,5
mnp
by mile
4 Facility's Owners On-Site Manager:
�J�
Vane.
5 General Contractor:
Shearer & Snide Inc dba/Ace Asbestos 716 Pine Meadow Rd .
Name
AOOress
Northfield MA. 01360
City/Town
Lo mile
Granite State Ins'. Co. WC /25-O9-62
Contractors workers Comp.Insurer
AUpe„
elmom
&Mode Telephone
Policy/
6. What is the size of the facility?,i5X5/O(sg ft)_(t of floors)
413 498-0201
Telephone
Exp.Dale
ElAsbestos 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 .
Wane
Address
Northfield MA 01360 413 498-0201
City/Tom
hp wale rererome
2 Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site:
same as above
na,ne
Addles.
Note.' Transfer CJIAO+e,
SbF.....�.... Zip rile IeleMalu
INSTRUCTIONS
All sections al this
orm must be completed
n mater to comply Oh
he Department ot
Environmental
Protection notilcation
requirements ot 310 CMR
7.15 (tso wwkinp days
prior nalifiCalion Is
requried atanyabafement
platec0:andthe
Department of Labor
and Industries
notileation requir ements
of 453 CMR 612 (len
days pliot nadcaton is
repaired ofANY
abatement pwecl greater
Than three areal or
spuate feetI.
2. Submit Original Form
To:
Commonwealth of
Massachusetts
Asbestos Program
P.O.B.120087
Boston,MA 02112-
0087
3. This Corm may be
used for noldymg Ne
U.S.Environmental
Protection Aciency Region
of asbestos demolhioN
renovation operations
subject to NESHAPS(40
Commonwealth of Massachusetts
Asbestos Notification Form — ANF•00f
Asbestos Abatement Description
1. Facility location:
53o e 1MurstorN ce SIdQ'A02-,
Aamess
xa,�e
V1QYea.ca__._MA
Ciry/rowrl
,SZrv?eent
Ka a me wIXbile ltryroni Wdailp carte,/,wing,toot tow
2. Is the facility occupied? IS Yes 17 No
3 Asbestos Contractor'.
agia RJDee ?.t4_ '
D1Olab
Zip rule
Shearer & Snide Inc dba/ACe Asbestos
... , ....._...._... Address
Name
Northfield MA . 01360
common
AC000006
IXl Ljcese/
4. On-Site Project Supervisor/Foreman.
Ed Shearer/Tom Shearer
Nave
5. Project Monitor:
Name
B. Asbestos Analytical Lab:
F/IV1Ron;MA71% 5p0-170 o6
None —TE-ST{JG
7. Project startdate1l11)00 end dateroll1l9
8. What type of project is this? (circle one). 067701111011
hO We I
W r.i'resl
contract IrR(wrmoLeIOa1)
=EI3- 5BrJ-Q4 -
felepmne
716 Pine Meadow Rd .
413 498-0201
lelepnone
AS70245 , AS70066
DV Sealliatw✓
IXl Certlicaaou
IXl
Cent annum/
o30 3o Sat.Sun.)—
specifipworkhours(Mon Fri.) 0 a" ( Update
teat
repast Amronlion'3 .061 izx./
system
comply with the
Solid Waste
Division regula-
tions 310 CMR
18.00
3. Refuse transfer station and owner(if applicable):
N/A
No,1e Addrzrt
Ciy/Town
4 Final Disposal Site:
Valley Landfill
lip tale Telephone
Waste Management/ Logano Trucking
canon Name (MMUS Name
Pleasant Valley Rd .
Irwin PA 15642 724 744-7446
D
Certification
The undersigne d he Eby states, under the penalties of perjury,that he/she has read the Commonwealthnl Mawohlisxttx Regulath
for the Removal.Containment or Encapsulation of Asbestos.453 CMR 6.00 and 310 CMR 7.15,and that the information container
this notification is true and correct to the best of hisller knowledge and belief.
iclaia rat 'D 3 Aen,er er ea- ?Not
pm!Name AumoNNSinn/une (bile
Note:Contractor Shearer & Snide Inc. dba/
must sign this Ace Asbestos Removal 413 498-02
form for OLI Pm/Irn/Tine
RPDIPYnllnp telephone
notification
purposes 716 Pine Meadow Rd . Northfield , MA. 01360
Mole” f tj/Toxn hp axle
Fee exempt(City,Town,district.municipal housing authority,owner-occupied residential of four units or less)Ayes ❑ n
m7
Sticker!(from front of form): / / 3 I
Mal Use unn
awn
a m.
haaaaaa
sada
Rev 652
9. Describe the asbestos abatement procedures to be used (circle): pee t set—up variable ab e air pressure ,
enrapsuladon msmarroaf omerterPm/ poly work area , HEPA vac , HEPA
filter reepirator , wet asbestos
10. Is the lob being conducted X indoors C outdoors? handled on
11. Total amou of each type oSAsbestos to be removed, enclosed ore encapsulated:
or ducts(linear h.)
.220 of other
surfaces(square tt.)
linear/square lee(
Doile/,breaching.du..lank surface coatings_.__J 31, 0erma/solid ore pipe insulation
�-
ieinsulation_..02/_ insulating cement —�
mnuga(Mwlayeredpapw pipe ____/____ trowel/sprayer coatings
splay-on yep/oaing ___/_____ transits bond,wall bov0
cloths, Ie woven describe
_l-
athe(please describel
12. Describe the eoutlt v
system(s) used:
3 chamber decon unit w/tiarm •.va ter
shower
Y vlc s ts ,HEPA vac for clean—up. _
13. Describe the containerization/disposal methods to comply with 3110 CMRe7.15 and 453 CMo o (2)(g) as
Sewet asbestos & FaC,; in
labeled
before removal from site .
14. For Emergency Asbestos Abatement Operations,the DEP and DLI officials who evaluated the emergency
rule
nee
DaeaAullu anei
wrar/
15. Do prevailing wage rates apply as per M.G.L.c. 149,5 26,27,or 27A-F to this project? C Yes X No