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