241 #2 Asbestos Notification Form 2003 11/4) Asbestos Notification Form ANF-001
REVISED 09/23/03 (117)
Commonwealth Massachusetts
77o $77
Please Enter Decal#
772397
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JSTRUCTIONS
.All sections of
its form must be
ompleted in order
comply with
EP notification
rquirements of
10 CMR 7.15
nd the Division
f Occupational
afety(DOS)
otification
:quirements of
53 CMR 6.12
A. Asbestos Abatement Description
Facility Location:
Hampshire Heights Building#2
241 Jackson Street
Name of Facility
Northampton
City/Town
Worksite Location:
Kitchen, Bathroom &2nd Floor Hall
MA
State
Street Address
01060
Zip Code
NA
Building name,#,wing,floor,room.
2. Is the facility occupied? ❑Yes ® No
3. Asbestos Contractor:
AccuTech Insulation & Contracting, 100 State St., P.O. Box 376
Name Address
4.
5
6
Submit Original
orm to:
ommonwealth of
lassachusetts 7
sbestos Program
0 Box 120087
cston MA
2112-0087
SEP 27_03 j L»
` 1
IAMPTON BOARD OF HEALTH
Ludlow, MA 01056 (413)583-5500
City/Town Zip Code Telephone
AC000005
DOS License# Contract Type:
Scott Dunbar Estimator
Written ❑Verbal
Facility Contact Person Contact person's title
Dale Hardy AS71733
Name of On-Site Supervisor/Foreman DOS Certification#
To be determined
Name of Project Monitor
To be determined
DOS Certification#
Name of Asbestos Analytical Lab DOS Certification#
10/01/ 3 10/03/03
Project Start Date
10/06/03
End Date
7AM -5 PM NA
Work hours Mon-Fri. Work hours Sat-Sun.
8. What type of project is this?
❑ Demolition
❑ Repair
� Renovation
❑Other, please specify:
9. Check abatement procedures:
❑ Glove bag
❑ Enclosure
❑Cleanup
❑ Full containment
❑ Encapsulation
❑ Disposal only
® Other, specify: VAT/Mastic
10. Is the job being conducted: Indoors? ❑ Outdoors?
Notification.doc•9/02 Asbestos Notification Form•Page 1 of 4
Commonwealth Massachusetts
Asbestos Notification Form ANF-001
77437.7
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
Cornigated or layered paper pipe
insulation
Spray-on fireproofing
Cloths.woven fabrics
Thermal,solid core pipe insulation
/1000
lin.ft sq.ft
fin.ft sq.ft
/
fin.ft sq.ft
fin.ft sq.ft
lin.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
d mn sea_
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
Title
Waiver#
Title
Date of Authorization Waiver#
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
1. Current or prior use of facility
Residence
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes Z No
Northampton Housing Authority • 49 Old South Street
3' Facility Owner Name Address
Northampton 01060 (413)584-4030
City/Town Zip Code Telephone
4 John Hite Same as above
Name of Facility Owner's On-Site Manager Address
Citylfown
Zip Code Telephone
Notification.doc•9/02 Asbestos Notification Form•Page 2 of 4
e:Transfer
tions must
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id Waste
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e: Contractor
st sign this form
DOS notification
poses
Commonwealth rMassachusetts
p
Asbestos Notification Form ANF-001
77A312
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B. Facility Description (cont.)
BC! Construction
5-
Name of General Contractor
Albany,
City/Town
Granite State Insurance
12204
Zip Code
Contractors Workers Comp.Insurer
6. What is the size of this facility?
20 Loudonville Road
Address
(518)426-3200
Telephone
7252577
Policy#
7200
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:
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:
Waste Management N.E.E.T., Inc.
Name of transporter
Portland, CT 06480
City/Town Zip Code
3. N/A
Refuse transfer station and owner
25 Silver Street
(860) 342-0667
Telephone
Address
City/Town Zip Code
4. Turnkey Recycling & Environmental Enterprise
Final Disposal Site location name
97 Rochester Neck Road
Address
NH
State
03839
Zip Code
Telephone
Turnkey Recycling & Environmental Enterprise
Owners Name
Gonic
City/Town
(603)330-0217
Telephone
D. Certification
otification.doo•9/02
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
PositlonTtle
(413)583-5500
Telephone
Ludlow, MA
City/Town
AAihodzed 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?) 0 Yes 0 No
Asbestos Notification Form•Page 3 of 4