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Commonwealtf; ,f Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description
1. Facility Location:
Go West Building
Name of Facility
Florence
City/Town
Worksite Location:
Basement-3rd Floor
MA
State
777440
Please Enter Decal#
777440
OCT 2 0 200:
1 North Main StrqJ����"�.t
Street Address 1 LAINPIUN WAI1D(Jr HEALTI
01060 N/A
Zip Code Telephone
Building name,#,wing,floor, room.
2. Is the facility occupied? ❑ Yes Z No
3. Asbestos Contractor:
AccuTech Insulation &Contracting,
I.All sections of
his form must be
:ompleted in order
o comply with
)EP notification
equirements of
110 CMR 7.15
Ind the Division 4.
If Occupational
Safety(DOS) 5
iotification
equirements of
153 CMR 612 6.
?.Submit Original
:arm to:
Itommonwealth of
dassachusetts
Asbestos Program
DO Box 120087
3oston MA
)2112-0087
Notification•9/02
Name
Ludlow, MA
City/Town
AC000005
DOS License#
Joanne Campbell
01056
100 State St., P.O. Box 376
Address
(413)583-5500
Zip Code
Facility Contact Person
Dale Hardy
Telephone
Contract Type: Z Written ❑Verbal
Contact person's title
AS71733
Name of On-Site Supervisor/Foreman
To be determined
DOS Certification#
Name of Project Monitor
To be determined
DOS Certification#
Name of Asbestos Analytical Lab
7 01/15/2005
Project Start Date
7 AM to 4 PM
DOS Certification#
02/15/2005
Work hours Mon-Fri.
8. What type of project is this?
❑ Demolition ® Renovation
❑ Repair ❑ Other, please specify:
9. Check abatement procedures:
® Glove bag
❑ Enclosure
❑ Cleanup
® Full containment
10. Is the job being conducted: ® Indoors? ❑ Outdoors?
❑ Encapsulation
❑Disposal only
❑Other, specify:
End Date
N/A
Work hours Sat-Sun.
Asbestos Notification Form•Page 1 of 4
Commonwealth .f Massachusetts
� Asbestos Notification Form ANF-001
777440
Please Enter Decal#
A. Asbestos Abatement Description (cont.)
11. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
515
pipes or ducts(linear ft)
Boiler,breaching,duct,tank surface
coatings
Corrugated or layered paper pipe
insulation
Spray-on fireproofing
Cloths,woven fabrics
Thermal,solid core pipe insulation
lin.ft sq.ft
515/
lin.ft sq.ft
Mn.ft sq.ft
lin.ft sq.ft
lin.ft sq.ft
16,660
other surfaces(square ft)
Insulating cement
Trowel/Sprayer coatings
Transite board,wall board
Other,please spedfy:
4,375 sq.ft.VAT&Mastic 21 sq.
ft cink nnafinn
tin.ft sq.ft
/7 835
lin.ft sq.ft
lin.ft sq.ft
lin.ft sq.ft
12. Describe the decontamination system(s)to be used:
Two layers of 6 mil poly on the walls and floor(where applicable)with an attach. 3 stage decon unit.
Seal critical with 6 mil poly pre-clean, lay drop cloth & remove using neg press glovebag method.
13. 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 company vehicle to
dl tmn sift
14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
Notification•9/02
N/A
Name of DEP official Title
Date of Authorization Waiver#
N/A
Name of DOS official Title
Date of Authorization Waiver#
15. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? ❑Yes Z No
B. Facility Description
Retail & Residential
1. Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or less?
❑Yes El No
Valley CDC 30 Market Street
3' Facility Owner Name Address
Northampton 01060 413-586-5855
City/Town Zip Code Telephone
Joanne Campbell same as above
4' Name of Facility Owner's On-Site Manager Address
City/rown
Zip Code Telephone
Asbestos Notification Form-Page 2 of 4
CommonwealtF. F Massachusetts
kAsbestos Notification Form ANF-001
rte:Transfer
ations must
mply with the
:lid Waste
vision
>gulations 310
AR 19.000
777440
Please Enter Decal#
B. Facility Description (cont.)
Western Builders PO Box 587
5.
Name of General Contractor Address
Granby 01033 413-467-9171
City/Town Zip Code Telephone
Granite State Insurance WC481-49-86
Contractors Workers Comp.Insurer
6. What is the size of this facility?
Policy#
8,400
Square Feet
11/04/04
Exp.Date
3
#of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary)to final
disposal site:
AccuTech Insulation & Contracting, Inc. 100 State Street, P.O. Box 376
Name of transporter Address
Ludlow, MA 01056 (413) 583-5500
City/Town Zip Code Telephone
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
Waste Management N.E.E.T., Inc. 25 Silver Street
Name of transporter Address
ote:Contractor
lust sign this form
/r DOS notification
urposes
Notification•9/02
Portland, CT 06480 (860)342-0667
City/Town Zip Code Telephone
3. N/A
Refuse transfer station and owner Address
City/Town Zip Code Telephone
4. Turnkey Recycling & Environmental Enterprise Turnkey Recycling & Environmental Enterprise
Final Disposal Site location name Owner's Name
97 Rochester Neck Road Gonic
Address City/Town
NH 03839 (603) 330-0217
State Zip Code Telephone
D. 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.
Grace Mitchell
Name
Office Manager
Position/Title
(413)583-5500
Telephone
Ludlow, MA
City/Town
orized Signs l• a and Date
AccuTech Insula ion &
Contracting, Inc.
100 State St, P.O. Box 376
Address
01056
Zip Code
Fee exempt(city,Town,district,municipal housing authority,owner-occupied residential of four units or less?) ®Yes ❑No
Asbestos Notification Form•Page 3 of 4