241 #9 Asbestos Notification Form 2003 (2) Commonwealth a Massachusetts
LiAsbestos Notification Form ANF-001
729? SIN
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
in.ft sq.ft
lin.ft sq.ft
lin.ft sq.ft
lin.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
di inn Rant
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
Residence
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
3. Facility Owner Name Address
Northampton 01060 (413)584-4030
City/Town Zip Code Telephone
John Hite Same as above
4. Name of Facility Owner's On-Site Manager Address
City/Town
Zip Code Telephone
Notification doc•9/02 Asbestos Notification Form•Page 2 of 4
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INSTRUCTIONS
1.All sections of
this for must be
completed in order
to comply with
DEP notification
requirements of
310 CMR 7.15
and the Division
of Occupational
Safety(DOS)
notification
requirements of
453 CMR 6.12
Commonwealt1 i Massachusetts
77437
Please Enter Decal#
Asbestos Notification Form ANF-001
772396
A. Asbestos Abatement Description
1. Facility Location:
Hampshire Heights Building#9
Name of Facility
Northampton MA
City/Town State
Worksite Location:
Kitchen, Bathroom &2nd Floor Hall
Building name,#,wing,floor,room.
2. Is the facility occupied? ❑Yes E No
3. Asbestos Contractor:
AccuTech Insulation &Contracting,
4
5
6
2.Submit Original
Form to:
Commonwealth of
Massachusetts 7.
Asbestos Program
PO Box 120087
Boston MA
02112-0087
Name
Ludlow, MA
City/Town
AC000005
DOS License#
Scott Dunbar
241 Jackson Street
Street Address
01060 NA
Zip Code Telephone
01056
Zip Code
Facility Contact Person
Dale Hardy
Name of On-Site Supervisor/Foreman
To be determined
r- J \:11 y
_t1
SEP - 42003
•;P-0. BOAR_OF HEALTH
100 State St., P.O. Box 376 - - - �_.
Address
(413) 583-5500
Telephone
Contract Type: E Written ❑Verbal
Estimator
Contact person's title
AS71733
DOS Certification#
Name of Project Monitor
To be determined
Name of Asbestos Analytical Lab
09/24/03
DOS Certification#
Project Start Date
7AM -5 PM
Work hours Mon-Fri.
8. What type of project is this?
❑ Demolition E Renovation
❑ Repair ❑ Other, please specify:
9. Check abatement procedures:
DOS Certification#
09/26/03
End Date
NA
Work hours Sat-Sun.
❑ Glove bag ❑ Encapsulation
❑ Enclosure ❑ Disposal only
❑ Cleanup E Other, specify: VAT/Mastic
E Full containment
10. Is the job being conducted: E Indoors? ❑Outdoors?
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