1 Asbestos Notification Form 2009 Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
olas
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100086966
Decal Number
A. Asbestos Abatement Description
a. Is this facility fee exempt-city,town,district, municipal housing authority,owner-occupied
residence of four units or less? 0 Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
HASKELL BUILDING
a.Name of Faality
NORTHAMPTON
c.City/Town
3. Worksite Location:
1.All sections of this
form must be
completed in order
to comply w+th 4
DEP notification
requirements of 310
CMR).15 5
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
GMR 6.12
0
N
RMS.117, 119 8120
a.Building Name/Building Location
Is the facility occupied?
Asbestos Contractor:
rA
MA
d.State
b.Building#
Yes ❑No
ACCUTECH INSULATION 8 CONTRACTING ID
a.Name
LUDLOW
c.City/Town
1A0000005
f.DOS License Number
RAE ANN CHASE
h.Facility Contact Person
01056
d.Zip Code
SAMUEL JUSINO
6. a.Name of On-Site Supervisor/Foreman
IOTO
7. a.Name of Project Monitor
8.
OTO
a.Name of Asbestos Analytical Lab
105/09/2009
a.Project Start Date(mm/ddyyyy)
N/A
c.Work hours Mon-Fri.
10 a What type of project is this?
❑Demolition ri Renovation
❑ Repair ❑Other, please specify:
11. a. Check abatement procedures:
0 ❑Glove bag
❑Enclosure
❑ Cleanup
Full containment
z
17
❑ Encapsulation
❑ Disposal only
❑Other, specify:
Blanket Decal Number
1 PRINCE STREET
b.Street Address
01061
e.Zip Cade
c.Wng
(413)587-6413
f.Telephone Number
d Floor
e.Room
100 STATE STREET
b.Address
4135835500
e Telephone Number
g.Contract Type:
17
Written ❑Verbal
Contact Person's Title
AS001028
b.Supervisor/Foreman DOS Certification Number
AM071138
b Project Monitor DOS Certification Number
AA000089
b.Asbestos Analytical Lab DOS Cedification Number
05/10/2009
b.End Date(mmiddiyyyy)
7:30-5:00
d.Work hours Sat-Sun.
12. Is the job being conducted: 0 Indoors? ❑Outdoors?
anf001ap.doc•10/02
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Asbestos Notification Form•Page 1 of 3
SEAL CRITICALS W/6MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNIT S INSTALL AIR f
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100086966
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed, or
encapsulated:
0
a.Total pipes or duds(linear ft)
c.Boiler,breaching,duct.tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g Spray-on fireproofing
i.Cloths.woven fabrics
k.Thermal,solid core pipe
insulation
358
b. total other surfaces(square ft)
Lin_ft.
Sq ft
Lin.ft. Sq.ft.
Lin
Lin.R.
Lin.fl.
Sq.f
Sq.fl.
14. Describe the decontamination system(s)to be used
d Insulating cement
f TroweVSprayer coatings
h.Transite board,wall board
j.Other.please specify:
Lin.ft. Sq.ft-
Lin.8. Sq.ft.
Lin.ft
Lin.ft.
358
VAT ONLY
I.Spedty
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
ACM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a Name of DEP Official
c.Date lmm/ddlyyyy)of Authorization
e.Name of DOS Official
g.Date(mm/dd/yyyy)of Authorization
b.Tle
d.DEP Waivers
.DOS Offoal Tlue
h.DOS Waiver#
17 Do prevailing wage rates as per M.G.L.c. 149, §26, 27 or 27A—F apply to this project? t7 Yes❑No
° B. Facility Description
0
LL
z
1
2
3
4
Current or prior use of facility:
MENTAL HEALTH HOSPITAL
Is the facility owner-occupied residential with 4 units or less?
DEPARTMENT OF MENTAL HEALTH
a.Facility Owner Name
NORTHAMPTON
c.City/Town
01061
d.Zip Code
RAE ANN CHASE
• anf001ap.doc•10102
a.Name of Fadlity Owners On-Site Manager
c.City/Town
d.Zip Code
❑Yes
No
P.O. BOX 389
b Address
413-587-6413
e.Telephone Number(area code and extension)
b.On-Site Manager Address
413-587-6413
e.Telephone Number area code and extension)
Asbestos Notification Form•Pa ea a 2
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
r�►
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
'100086966
Decal Number
B. Facility Description (cont.)
5.
a Name of General Contractor
c.City/Town
d Zip Code
COMMERCE&INDUSTRY
f.Contractors Worker's Comp.Insurer
6. What is the size of this facility?
b.Address
e.Telephone Number(area cod and extension)
11/04/2009
h.Exp.Date(mm/ddlyyyy)
1 14
b.Number of floors
WC5312904
9.Policy Number
184,000
a.Square Feet
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
ACCUTECH INSULATION &CONTRACTING
a.Name of Transporter
'LUDLOW
c.City/Town
01056
d.Zip Code
100 STATE STREET
b.Address
(413) 583-5500
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
3
4
RED TECHNOLOGIES
a.Name of Transporter
'PORTLAND
c.City/Town
06480
d.Zip Code
173 PICKERING STREET
b.Address
(860)342-1022
e.Telephone Number
a.Refuse Transfer Station and Owner
c.City/Town
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
d.Zip Code
b Address
II
9000 MINERVA ROAD
c.Final Disposal Site Address
OH
e.State
44688
fi Zip Code
e.Telephone Number
b.Final Disposal Site Location Owner's Name
WAYNESBURG
d.City/Town
g.Telephone Number
D. Certification
The undersigned hereby states,under the
o p th f perjury,that he/she has read the
o Commonwealth of Massachusetts regulations
for the Removal,Containment or
E caps I C f A bestos,453 CMR 6.00 and
310 CMR 7.15, and that the information
toned in this notification is true and correct
o to the best of his/her knowledge and belief
I.
Z
anf001ap doc•10/02
HEATHER R. CREPEAU
a.Name
OFFICE MANAGER
c.Positiowritle
(413)583-5500
e.Telephone Number
'100 STATE STREET
g.Address
'LUDLOW
h.City/Town
d.Date Imm/dd/
ACCUTECH
f.Representing
01056
i Zip Code
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Asbestos Notification Form•Page 3 of 3•
Important:
When filling out
forms on the
9 computer.use
ekp only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
1. This form is
only available for
online filing of
project date
revisions.
2. Enter project
decal number.
3. Validate that
the project
location is correct
for the entered
decal.
4. Enter your new
project dates.
5. Certify your
notification.
Submit date
changes.
a
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100084731
Decal Number
A. Facility Location
HASKELL BUILDING
1.Name of Facility
1 PRINCE STREET
2.Street Address
[-NORTHAMPTON
3.City 5.Zip Code
413 5876413
6.Telephone Number
[MA
4.State
B. Project Cancelled
Check here if this project is/was cancelled.
C. Project Dates
03/03/2009
1 Ori.inai Start Date mmldd
M
3.Latest Revised Start Date(mmldel/yyyy)
103/04/2009
2.Or'ainal End Date(mnvdd/rvyy)
J l
4.Latest Revised End Date(mmlddlyyyy)
D. Revised Project Dates
03/07/2009
1.Revised Start Date(mm/dd/yyyy)
[03/08/2009
2.Revised End Date Date(mnVdd/yyyy)
1
E. Other Project Revisions
CORRECT ANSWER TO SECTION A. QUESTION 90.IS: 7:30-4:30,WORK WILL BE
PERFORMED ON SATURDAY AND SUNDAY,NOT MON-FRI.
anfo6pdm.doc•rev.2/5/04
Amok
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention —Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
100084731
Decal Number
G. Certification
The undersigned hereby states, under the penalties of perjury,that he/she has read the Commonwealth of
Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos.453 CMR 6.00 and 310
CMR 7.15,and that the information contained in this notification is true and correct to the best of his/her knowledge
and belief.
!HEATHER R. CREPEAU
1. N
OFFICE MANAGER
2. Poston/Title
ACCUTECH INSULATION &CONTRACTING
a. Representing
100 STATE STREET
6. Address
LUDLOW
7. Gity/Town
anf06pdmdoc•rev.2/5/04
Authorized innalur
103103/2009
3. Date(mmldd/wwl
(413) 583-5500
5. Telephone
01056
8. Zip code
t'
'
•••••
ACCUTECH INSULATION &CONTRACTING It
..10Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
Important:
Wnen filling out
fors on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
■
100084731
Decal Number
A. Asbestos Abatement Description
a. Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied
residence of four units or less? 0 Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
HASKELL BUILDING
a.Name of Facility
NORTHAMPTON
c.City/Town
3. Worksite Location:
1.All sectons of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR 715 5.
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 6.12
MA
d.State
Blanket Decal Number
1 PRINCE STREET
b Street Address
01061
e Zip Code
a.Building Name/Building Location P b.Building# 1
ROOM 263
Is the facility occupied? p Yes ❑No
Asbestos Contractor:
a Name
LUDLOW
C.City/Town
AC000005
f.DOS License Number
01056
d Zip Code
RAEANN CHASE
h.Facility Contact Verson
(413) 587-6413
f Telephone Number
c.Wing d.Floor
e.Room
100 STATE STREET
b.Address
4135835500
e.Telephone Number
g. Contract Type:
11
Written ❑Verbal
i.Contact Person's Title
BRANDON E. BESAW
6. a.Name of On-Site Supervisor/Foreman
7' a.Name of Project Monitor
O'REILLY, TALBOT&OKUN
8. a.Name of Asbestos A.nalytica!La
O'REILLY,TALBOT&OKUN
9 a.Proj
03/03/2009
Start Date(mm/dd/yyyy)
7:30-4:30
c.Work hours Mon-Fri.
10 a What type of project is this?
❑ Demolition
❑ Repair
151
Renovation
❑ Other, please specify:
11. a. Check abatement procedures:
o ❑ Glove bag ❑ Encapsulation
o ❑ Enclosure ❑ Disposal only
❑ Cleanup ❑ Other, specify:
Full containment
Z
17
AS070407
b Supervisor/Foreman DOS Certification Number
AM071138
b.Project Monitor DOS Certification Number
AA000089
b.Asbestos Analytical Lab DOS Certification Number
03/04/2009
b End Date(mmlddlyyyy)
FI/A
d Work
ni sii i.
b.Descri I' 1 s 11' "IP
b.Describe
12. Is the job being conducted: [ Indoors? ❑Outdoors?
anf00lapdoc•10/02
Go To Top
Asbestos Notification Form•Page 1 of 3
•
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
O
•
100084731
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed,enclosed, or
encapsulated:
0
a.Total pipes or ducts(linear ft)
c.Boiler,breaching,duct,tank
surface coafirgs
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
270
b. !dal other surfaces(square fl)
Lin.ft
Lin.ft
Lin.fl
Lin.ft.
Lin.fl.
Sq.ft.
Sq.fl.
Sq.ft.
O.Insulating cement
f Trowel/Sprayer coatings
h Transite boats,wall board
j.Other,please specify:
S .ft
Lin ft
Lin.ft.
Lin ft
Sq.X.
Sq.fl.
Lin.fl.
270
Sq.ft.
VAT
Sq.ft I.Speciry
14. Describe the decontamination system(s)to be used
SEAL CRITICALS W/6MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNIT AND INSTALL
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
ACM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
N/A
a.Name of DEP Official
c.Date(mmlddryyyy)of Authorization
N/A
e.Name of DOS Official
b.Title
d DEP Waiver#
f.DOS Official Title
g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver#
17 Do prevailing wage rates as per M.G.L.c. 149, §26, 27 or 27A—F apply to this project?n Yes❑ No
B. Facility Description
1 Current or prior use of facility:
HOSPITAL
2. Is the facility owner-occupied residential with 4 units or less?
3' a.Facility Owner Name
DEPARTMENT OF MENTAL HEALTH
NORTHAMPTON
o c.City/Town
IRAEANN CHASE
4' a.Name of Facility Owner's On-Site Manager
Z
01061
d.Zip Code
anf001ap.doc•10/02
c.City/Town
d.Zip Code
❑Yes 0 No
P.O.BOX 389
L Address
(413) 587-6413
e.Telephone Number(area code and extension)
b.On-Site Manager Address
(413) 587-6413
e.Telephone Number(area code and extension)
Asbestos Notification Form Pa ea a 2
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100084731
Decal Number
B. Facility Description (cont.)
5.
a.Name of General Contractor
c.City/Town
COMMERCE&INDUSTRY
f Contractors Workers Comp.insurer
6. What is the size of this facility?
d Zip Code
J
b.Address
e.Telephone Number(area
WC5312904
q.Policy Number
84,000
a.Square Feet
code and extension)
11/04/2009
h Exp.Date(mmlddtyy )
4
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
ACCUTECH INSULATION &CONTRACTING
a.Name of Transporter
LUDLOW
a Cy/Town
01056
d.Zip Code
2. Transporter of asbestos-containing waste material
3.
4.
RED TECHNOLOGIES
a.Name of Transporter
PORTLAND
c.Ciy/rown
06480
d.Zip Code
a.Refuse Transfer Station and Owner
c.Ciy/Town
d Zip Code
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
1OH
e.State
44688
f Zip Code
100 STATE STREET
b.Address
(413)583-5500
e.Telephone Number
from removal/temporary site to final disposal site:
173 PICKERING STREET
b.Address
(860) 342-1022
e.Telephone Number
b.Address
e.Telephone Number
b Final Disposal Site Location Owners Name
LAYNESBURG
d.City/Town
g.Telephone Number
D. Certification
The undersigned hereby states, under the
° p It f p rj ry,th t h /she has read the
C Ith f M achusetts regulations
for the Removal,Containment or
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15,and that the information
contained in this notification is true and correct
° to the best of his/her knowledge and belief.
0
2
anr001ap.doc•10/02
DANIELLE DEMERS
a.Name
ADMIN.ASSISTANT
c.Position/Title
(413)583-5500
e.Telephone Number
100 STATE STREET
q.Address
LUDLOW
h.City/Town
L, ,1t112)4ei 22.WUCJ
b.Authorized Signature
02/18/2009
d.Date(mm/ddNVw)
ACCUTECH
f.Representing
J
01056
Zip Code
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Asbestos Notification Form•Page 3 of 3