1 Asbestos Notification Form 2004 L-11
Asbestos Notification
CommonwealtL.f Massachusetts
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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
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Asbestos Notification Form•Page 1 of 3
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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
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Asbestos Notification Form•Page 3 of 3 II