1B Asbestos Notification Form 2003 Commonwealth of'assachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description
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»AR 7.15
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Facility Location:
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Name of FaWly
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City/Town
Worksite Location:
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N4 768719
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enuring .ft.wing.nor.mom.
2. Is the faality occupied? R Yes ❑No
3. Asbestos Contractor.
4.
1 to:
monwealtir of
mchusees 7.
sloe Prom
lox 120067
on'AA
129087
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N' --HAMPTON BOARD OF HEAL:
Address
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_ Zip Cade
a C. 0 00 249
DOS License*
Fac�ty COnlacI Pelson
(-4-\
Name of OnSde SupennsodForentan
Name of Project Monitor
^
Name of Asbestos Analye°l lab
I n — 3
Project Stan Dale
3-am -
Week tours Mon-Fri.
8. What type of project is this?
Demolition ❑Renovation
❑ Repair ❑Other,please specify:
9. Check abatement procedures:
❑Glove bag
❑Enclosure
❑Cleanup
jnFull containment
10. Is the job being conducted: )Indoors? ❑ Outdoors?
❑Encapsulation
❑Disposal only
❑Other,specify:
Telephone
Contract Type: El Written
pcJroet
Contact peson5 Idle
DOS/%diication
r-11 —4k%
DOS Catamaran*
M
DOS Certification
10- a
End Date
Work ban Sat-Sun.
n1001 ap.doc-0/02
—03
❑Verbal
Aube rypy(caCOn Form.Page 1 of 4
Commonwealth ot;/4assachusetts
a
Asbestos Notification Form ANF-001
b89-1c1
Please Enter Decal ft
A. Asbestos Abatement Description (cont.)
11. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
pipes or duds(linear ft)
Boder,Stashing,duct,tank surface
coatings
Corrugated or layered paper pipe
insulation
Spray-on fireproofing
Cloths,woven fabrics
Thermal,solid core pipe insulation
)WD' K
6n.ft sq.it
/
fin.It sq.ft
/
lin.ft sq.,ft
fin.ft sq.ft
/
rm.ft sq.ft
other surfaces(square ft)
Insulating cement
Trowel/Sprayer coatings
Trance board,wall board
Other,please spedrr
ikft
6n.ft
/
sq.ft
/
sq.ft
fin.ft sq.ft
/
lin.ft sq.ft
12. Describe the decontamination system(s)to be used-
1-h4_e.4 YiC +m
13. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(g):
arner.cteA ,..> J t 2Cb>~.tISlr�S �.rcongoc\ LA/ AVtt
14. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
Name of DEP official Tab
Date ofAuNmtration Warier it
Name of DOS official Tab
Date ofAuthonzation Waver
15. Do prevailing wage rates as per M.G.L c. 149,§26,27 or 27A-F apply bs this project?❑Yes❑No
B. Facility Description
1. Current or prior use of facility:
2. Is the facility owner-occupied residential with 4
iSl s (iccaboWTh\-
3. Facility Owner Name
01obp
�Code
4.
p doe•9102
units or less? es ❑No
\\, NO:-:�'lSQVtt '?N_
cayrrpwn 1 �
Name of Facilytwnefs On-Site Manager
Cay/form Zip Code
Address
Telephone
Address
Telephone
Asbestos Notification Form•Page 2 of 4
e:Transfer
Icons must
py with the
id Waste
Mon 2. Transporter of asbestoscontainitg waste material from removal/temporary site to final disposal site:
Iuletions 310
R 19.000
Commonwealth 010411assachusetts
Asbestos Notification Form ANF-001
Phase Enter Donal*
B. Facility Description (cont.)
5. i�t,dctu ( o,..O lf.#turn Sts . P O '- C942
Name of Contractor Address
Sk id Code dea) 1--t t "�-R 2_ '2,200
City Zip C Telephone
Contractor's Worker's Corp.Insurer
6. What is the size of this facility?
Policy*
`TO0
Square Feet
Efp.Date
a_
*of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary)to final
Mse n t
rOLI lClo1arr an SO P n 3o-)e_ SC C(r1
Name of trmvpd�r Address
e rQ �\to1 ytt% ��,2 S20O •
C Zp Code Telephone
a Contractor
it sign this form
DOS notification
,058.5
k"-1 rte` VQ4A aLcin S.1.\ P o Got_ �i47
Name to�f'tra-n1spo Adder
Cll,nhoLm altar LEA% 'a-g 2 �2 OO
Zip Code Telephone
3. '
l sae..-. 12."(1/.In� �2�1 r[LlP 9 r� Cs .
��� station and owner
`t'o ARCaet C¢ of L Sfl �3a a 2'4-2 3Rtb2-
City/Town
4. jog _ t
Final Dares!
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Mtl 6s
Zp Code Telephone
State
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re code
ask,
C4y/rown
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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
two and correct to the best of hiisrtrer
knowledge and belief.
1001ap.doc•9102
t-{tct-s of rAoaRe
Name
_ _Cm.,,.]M 2
Position/The
Lr t 'S f) t as o0
Telephone
t13-litCC*-+2
Address
Reprrseneng
3PF
City/Teem
n1101 .
Zip Code
Fee exempt(cdy,Town,district,municipal housing authority,owner-occupied residential of four with;or less?)r 'Yes ❑No
Asbestos Noll bon Form•Page 3 of 4