241 #4 Asbestos Notification Form 2003 Commonwealth Massachusetts
Asbestos Notification Form ANF-001
5
A. Asbestos Abatement Description
1.
Facility Location:
Hampshire Heights - Bldg.#4
Name of Facility
Northam ton
City/Town
Worksite Location:
Kitchen, Bated Floor Hall
Building name,#,wing,floor,room.
2. Is the facility occupied? ❑Yes ® No
3. Asbestos Contractor:
AccuTech Insulation &Contracting_
Name
Ludlow, MA
City/Town
AC000005
DOS License#
Russ Gauthier
Facility Contact Person
Anthony Roy
4. Name of On-Site Supervisor/Foreman
To be Determined
Name of Project Monitor
To be Determined __
6. Name of Asbestos Analytical Lab
MA
State
rf
der
n
3
of
3inal
Ith of
is 7
gram
187
10122103
Project Start Date
7AM -5PM
Work hours Mon-Fri.
8. What type of project s this?
• Demolition ® Renovation
• Repair ❑Other, please specify:
01056
Zip Code
9. Check abatement procedures:
❑ Encapsulation
• Disposal only
• Other, specify:
• Glove bag
p Enclosure
Cleanup
® Full containment
10. Is the job being conducted: ® Indoors? ❑Outdoors?
772734
Please Enter Decal#
712734
241Jackson Street
Street Address
413 584— 4030
01060 -
Zip Code Telephone n F,
IN' -"HAMPTON BOARD OF HEALTH!
nit
100 State St., P.O. Box 376
Address
413 563-5500
Telephone
Contract Type:
Supervisor
Contact person's title
AS071233
DOS Certification#
DOS Certification#
DOS Certification#
10124/03
End Date
NA
Work hours Sat-Sun.
V.A.T.
ion.doc•9102
®Written ❑Verbal
Asbestos Notification Form•Page 1 of 4
Commonwealth Massachusetts
j Asbestos Notification Form ANF-001
772734
Please Enter Decal#
A. Asbestos Abatement Description (cord.)
11. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
pipes or ducts(linear ft)
Bailer,breaching,duct,tank surface
coatings
Corrugated or layered paper pipe
insulation
Spray-on fireproofing
Cloths,woven fabrics
Thermal,solid core pipe insulation
fin.ft sq.ft
/1000
lin.ft sq.ft
lin.ft sq.ft
tin.ft sq.ft
tin.ft sq.ft
1500
other surfaces(square ft)
Insulating cement
Trowel/Sprayer coatings
Transite board,wall board
Other,please specify:
VAT&Mastic
tin.ft
fin.ft
lin.ft
sq.ft
sq.ft
sq.ft
/500
fin.ft sq.ft
12. Describe the decontamination system(s)to be used:
Two layers of 6 mil poly on walls/floor with attached 3 stage decon unit. Seal criticals with 6 mil poly,
wet down with amended water and remove in whole while area is under neg pressure.
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
di inn alit;
14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
NA
Name of DEP official
Date of Authorization
NA
Name of DOS official
Date of Authorization
15. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A–F apply to this project? ®Yes❑ No
B. Facility Description
Title
Waiver#
Title
Waiver#
Residence
1. Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes 0 No
3 Northampton Housing Authority 49 Old South Street
Address
NorthOwner Name 01060 (413)584-4030
Northampton Zip Code Telephone
Jon Hit e Same as Above
Jon Hite — Address
4' Name of Facility Owners On-Site Manager
City/Town
:ion.doc•9/02
Zip Code Telephone
Asbestos Notification Form•Page 2 of 4
Commonwealth's Massachusetts
Asbestos Notification Form ANF-001
ster
ust
h the
s 310
Waste Management N.E.E.T., Inc.
772734
Please Enter Decal#
B. Facility Description (cont.)
BC! Construction
Name of General Contractor Address
Albany, NY 12204 NA
City/Town Zip Code
Granite State Insurance
5.
20 Loudonville Road
Contractor's Worker's Camp.Insurer
6. What is the size of this facility?
Telephone
7252577
Policy#
7200
Square Feet
11/04/03
Exp. Date
2
#of floors
C. Asbestos Transportation and Disposal
Transporter of asbestos-containing material from site to temporary storage site Of 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:
Name of transporter
Portland, CT
City/Town
3. N/A
25 Silver Street
06480 (860)342-0667
Zip Code
Telephone
Refuse transfer station and owner
Address
City/Town Zip Code
4. Turnkey Recycling & Environmental Enterprise
Final Disposal Site location name
97 Rochester Neck Road
Address
NH 03839
State Zip Code
Telephone
Turnkey Recycling & Environmental Enterprise
Owners Name
Gonic
City/Town
(603)330-0217
Telephone
'tractor
this form
iotification
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.
Brenda L. Shields
Name
Administrative Assistant
Position/Title
(413)583-5500
Telephone
Ludlow, MA
City/Town
thorized Signature and Date
AccuTech Insulation &
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
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