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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 Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. 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? Notification.doc•9102 Asbestos Notification Form•Page 1 of 4