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241 #9 Asbestos Notification Form 2003 Commonwealth . Massachusetts Asbestos Notification Form ANF-001 REVISED 09/23/03 (#7) A. Asbestos Abatement Description 1. Facility Location: Hampshire Heights Building#9 Name of Facility Northampton City/Town W orksite Location: Kitchen, Bathroom & 2n° Floor Hall Building name,#,wing,floor,roam. 2. Is the facility occupied? ❑Yes ® No MA State 3. Asbestos Contractor: AccuTech Insulation & Contracting, Name es Ludlow, MA City/Town of be AC000005 xder DOS License# Scott Dunbar on Facility Contact Person of Dale Hardy on 4' Name of On-Site SupervisonForeman ial 5. To be determined Name of Project Monitor of To be determined 2 6. Name of Asbestos Analytical Lab ginal ilth of lts 7. rgram ]87 09/26/03 Project Start Date 774374_ Please Enter Decal# 241 Jackson Street Street Address 01060 NA Zip Code Telephone 01056 Zip Code 772396 frt r i 1. SEP 2 6 2003 100 State St., P.O. Box 376 Address (413)583-5500 Telephone Contract Type: Estimator Contact person's title AS71733 DOS Certification# Written ❑Verbal DOS Certification# 7AM- 5 PM Work hours Mon-Fn. 8. What type of project is this? ❑Demolition ❑ Repair ® Renovation ❑Other, please specify: 9. Check abatement procedures: DOS Certification# 0tt2eteg— 09/30/03 End Date NA Work hours Sat-Sun. ❑ Glove bag ❑ Encapsulation ❑ Enclosure ❑Disposal only ❑ Cleanup ®Other, specify: VAT/Mastic ® Full containment 10. Is the job being conducted: ® Indoors? ❑ Outdoors? in.doc•9/02 Asbestos Notification Form•Page 1 of 4 Commonwealti-f Massachusetts i Asbestos Notification Form ANF-001 7297 5.7a 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: 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 /1000 lin.ft sq.ft lin.ft sq.ft fin.ft sq.ft lin.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 lin.ft sq.ft lin.ft sq.ft lin.ft sq.ft /500 lin ft sq.ft 12. Describe the decontamination system(s)to be used: Seal criticals with 6 mil poly,wet down with amended water and remove in whole while area is under negative 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 site 14. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: NA tle Name of DEP official Date of Authorization NA Name of DOS official Date of Authorisation 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 Waiver# Title Waiver# 1. Current or prior use of facility: 2. Is the facility owner-occupied residential with 4 units or less? ❑Yes ®No Northampton Housing Authority 49 Old South Street Address No 3' Facility Owner Name Northampton 01060 !4131 584-4030 City/Town Zip Code Telephone John of Hite Fa Same as above 4' Name of Facility Owner's On-Site Manager Address Zip Code Telephone Residence City/Town stion.doc•9/02 Asbestos Notification Form•Page 2 of 4 p Commonwealth c .Massachusetts Asbestos Notification Form ANF-001 772374 Please Enter Decal# B. Facility Description (cont.) BCI Construction 20 Loudonville Road 5 Address Name of General Contractor 12204 (518)426-3200 Albany, Zip Code Telephone City/Town 725257e Granite State Insurance Policy Contractor's Workers Comp.Insurer 7200 6. What is the size of this facility? Square Feet 11/04/03 Exp.Date 2 #of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site Of necessary)to final disposal site: State Street, P.O. Box 376 St 00 AccuTech Insulation &Contracting, Inc. 1 100 St Cud Name Ludlow, MA transporter 01056 (413)583-5500 City/Town MA Zip Code Telephone 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 25 Silver Street Waste Management N.E.E.T., Inc. Name of transporter 06480 (860)342-0667 Portland, CT City/Town Zip Code Telephone 3. N/A Refuse transfer station and owner City/Town Zip Code 4. Turnkey Recycling&Environmental Enterprise Turnke Re ec clip. &Environmental Enter Final Disposal Site location name Owners 97 Rochester Neck Road Address 03839 NH State Zip Code Telephone Address Telephone Gonic City/Town (603)330-0217 se for form ication 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. Fee exempt(city,Town,district,municipal housing r.doc•9/02 Brenda L. Shields Name Administrative Assistant Position/ritie (413)583-5500 Telephone Ludlow, MA City/Town authority,owner occupied residential Signature and Date AccuTech Insulation & Contracting, Inc. 100 State St, P.O. Box 376 Address 01056 Zip Code of four units or less?) ❑Yes ❑No Asbestos Notification Form•Page 3 of 4