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1 Asbestos Notification Form 2004 L-11 Asbestos Notification CommonwealtL.f Massachusetts Important When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. INSTRUCTIONS 1.All sections of this form must be completed in order to comply with DEP notification requirements of 310 CMR 7.15 and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 6.12 0 0 Z Q 100004633 Decal Number Affix Asbestos Notification Decal Here MAY 12 2004 A. Asbestos Abatement De A'r ---HA PT 1. a. is this facility fee exempt-citL,townrdistn4t®5E1 ��� � only,owner-occupied residence of four units or less? LiLI Yes ❑No b. Provide blanket decal number if applicable: 2. Facility Location: NORTHAMPTON STATE HOSPITAL a.Name of Facility Inorthampton c.Cby/Tawn 3. Worksite Location: [THROUGHOUT a.Building Name/Building Location 4. Is the facility occupied? 5. Asbestos Contractor: 6. a.Name of On-Site Supenisor/Foreman MA d.State 23 b.Building It Yes ❑No AIR QUALITY EXPERTS INC a.Name SALEM c.City/Town 1AC000167 f.DOS License Number 03079 tl.Zip Code h.Facility Contact Person GERMAN POSADA ZINIGA RICHARD SALVATELLI 7. a.Name of Project Monitor 8. IN/A a.Name of Asbestos Analytical Lab 9 105/24/2004 a.Project Start Date(mm/ddlwyy) 17AM-5PM c.Work hours Mon-Fri. 10 a What type of project is this? ❑Demolition N Renovation ❑Repair ❑Other, please specify: 11. a.Check abatement procedures: ❑Glove bag ❑Enclosure Cleanup Fullcontainment ❑ Encapsulation ❑ Disposal only Other,specify: --_—tr:Describe Blanket Decal Number 1 PRINCE ST b.Street Address 01060 e.Zip Code f.Telephone Number (413)587-6200 C.Win d.Floor e.Room 140 LOWELL RD UNIT 1 b.Address 6038946465 e.Telephone Number g. Contract Type: Written ❑Verbal I.Contact Person's Title AS032579 b.Supervisor/Foreman DDS Certification Number 1AM030636 b.Proles Monitor DOS Certification Number IN/A b.Asbestos Analytical Lab DOS Certification Number 105/28/2004 b.End Data(mm/dd/yyyy) d.Work hours Sat-Sun. b.Describe WHOLE PIECE REMOVA 12. Is the job being conducted. el Indoors? ❑Outdoors? ■ anf001apdoc•10/02 Go To Top Asbestos Notification Form•Page 1 of 3 L�. 0 1N 1. Current or prior use of facility: Commonwealth. A Massachusetts Asbestos Notification Form ANF-001 '100004633 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed,enclosed,or encapsulated: 1926 a.Total pipes or ducts(linear ff) 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 (605 b.Total other surfaces(square ft) Lin ft. 1846 L in.ft. L in.ft. L in.ft. Sq.ft. Sq.ft. S ft. Lin.n. Sq.n. 14. Describe the decontamination system(s)to be used: d.Insulating cement f.Trowel/Sprayer coatings h.Transits board,wall board J.Other,please specify. IWIND,LINO,B01 I.Specify Lin.ft Lin.ft. Lin.ft. 180 Lin.ft Sq.M. 'I sq.ft. 605 ' 3 CHAMBER DECON 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (q): 12 PLY WET POLYBAG 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: a.Name of DEP Official b.Title c.Date(mm/dd/yyyy)of Authorization J e. Name of DOS Official g.Date(mmlddlyyyy)of Authorization J d.DEP Waiver i f.DOS Official Title 1 h.DOS Waiver p 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 'HOSPITAL 2. Is the facility owner-occupied residential with 4 units or less? MASS DEVELOPMENT FINANCE AUTHORITII a.Facility Owner Name IDEVENS c.CM/Town 4' Ia.Name of Facility Owner's On-Site Manager 01432 d.Zip Code Z I I C c.City/Town an1001ap.doc•1(1/02 d.Zip Code ❑Yes O No 43 BUENA VISTA b.Address e.Tele hone Number area code and extension) b.On Site Manager Address ( e.Telephone Number(area code and extension) Asbestos Notification Form•Pa its=2 of 3 M i1 Note:Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19.000 N !®O n Commonwealtb. of Massachusetts Asbestos Notification Form ANF-001 '100004633 • Decal Number B. Facility Description (cont.) 'COSTELLO DISMANTLING 5. a.Name of General Contractor MIDDLEBORO c.City/Town (f.Contractors Workers Comp.Insurer 6. What is the size of this facility? 102346 d.Zip Code 12 ROCKY GUTTER ST b.Address 1508-946-0880 e.Telephone Number(area cod and extension) Q.Policy Number 140000 a.Square Feet h.Exp.Date(mm/dd/yyyy) b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site Of necessary): 'SAME AS CONTRACTOR a.Name of Transporter c.City/Town d.Zip Code b.Address e.Telephone Number 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 'PO BOX 2132 b.Address 'SERVICE TRANSPORT GROUP a. Name of Transporter 'BRISTOL c.City/Town 3. I 19007 d.Zip Code a. Refuse Transfer Station and Owner c.City/Town 4. 'A+ L SALVAGE INC. a.Final Disposal Site Location Name 111225 STATE ROUTE 45 c. Final Disposal Site Address 'OH e. State (877)999-9559 lI b.Address e.Telephone Number d.Zip Code II e.Telephone Number 44432 t Zip Code b.Final Disposal Site Location Owners Name LISBON d.City/Town g.Telephone Number D. Certification The undersigned hereby states, under the p It fp j y,th t h / h h d th C Ith f M h tt g I th R I C t t Encapsulation of Asbestos, 453 CMR 6.00 and 310 CMR 7.15,and that the information t ' d' th' ft' Y ' t d t to the best of his/her knowledge and belief. anf001ap Eoc•10/02 'CHRISTOPHER THOMPS" a.Name 'PRESIDENT c.Position/Tile (603)894-6465 e Telephone Number C b.Authorized Signature 105106/2004 d Date fmm/dd/vvvvl AIR QUALITY EXPERTS,' f.Representing ( 40 LOWELL RD UNIT 1 g.Address SALEM h.City/Town 03079 Zip Code Go To Top Asbestos Notification Form•Page 3 of 3 II