Loading...
241 #14 Asbestos Notification Form 2003 Important: NNhen filling out forms on the computer,use only the tab key to move your cursor-do not ise the return Key. INSTRUCTIONS Commonwealth Massachusetts Asbestos Notification Form ANF-001 A. Asbestos Abatement Description Facility Location: Hampshire Heights Building 14 Name of Facility Northampton City/Town Worksite Location: Kitchen, Bathroom &2nd Floor Hall Building name,#,wing,floor,room. MA State 241 Jackson Street Street Address 01060 Zip Code % 9751 Please Enter Decal# NQ 769751 N/A Telephone 2. Is the facility occupied? ❑Yes ® No 3. Asbestos Contractor: AccuTech Insulation & Contracting, 1.All sections of this form must be completed in order to comply with DEP notification requirements of 310 CMR 7.15 and the Division 4. of Occupational Safety(DOS) 5. notification requirements of 453CMR6.12 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 01056 Zip Code 100 State St., P.O. RItu ii I, JUN 17 2003L» t'aAMPTON BOARD OF HEALTH Box 376 Address (413)583-5500 Telephone Contract Type: Estimator ®Written ❑Verbal Facility Contact Person Dale Hardy Contact person's title AS71733 Name of On-Site Supervisor/Foreman To Be Determined DOS Certification# Name of Project Monitor To Be Determined Name of Asbestos Analytical Lab 07/25/03 DOS Certification if DOS Certification# 07/28/03 Project Start Date 7 AM to 4 PM End Date N/A Work hours Mon-Fri. 8. What type of project is this? ❑ Demolition ❑ Repair ® Renovation ❑Other, please specify: 9. Check abatement procedures: Work hours Sat-Sun. ❑ Glove bag ❑ Encapsulation ❑ Enclosure ❑ Disposal only ❑Cleanup ® Other, specify: VAT/Mastic ❑ Full containment 10. Is the job being conducted: E Indoors? ❑Outdoors? Notification BCI•9/02 Asbestos Notification Form•Page 1 of 4 s Commonwealth .,. Massachusetts 7075/ Please Enter Decal#/ v Asbestos Notification Form ANF-001 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 fin.ft sq.ft /400 fin.ft sq.ft fin.ft sq.ft lin.ft sq.ft / Iin.ft sq.ft 900 other surfaces(square ft) Insulating cement Trowel/Sprayer coatings Transite board,wall board Other,please specify: VAT/Mastic lin.ft lin.ft kn.ft sq.ft sq.ft sq.ft /500 lin.ft sq.ft 12. Describe the decontamination system(s)to be used: Two layers of 6 mil poly on the walls and floor with an attached 3 stage decontamination unit. 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 Allrnn alto 14. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: N/A Name of DEP official Title Date of Authorization N/A Waiver# Name of DOS official Title Date of Authorization Waiver# 15. Do prevailing wage rates as per M.G.I. c. 149, §26, 27 or 27A—F apply to this project? E 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 ® No Northampton Housing Authority 49 Old South Street 3. 4. Facility Owner Name Address Northampton 01060 413-584-4030 City/Town Zip Code Telephone John Hite same as above Name of Facility Owner's On-Site Manager Address City/Town Zip Code Telephone Notification BCI•9/02 Asbestos Notification Form•Page 2 of 4 Ask Commonwealth el Massachusetts - � Asbestos Notification Form ANF-001 tote:Transfer itations must simply with the iolid Waste Division iegulations 310 CMR 19.000 7L99751 Please Enter Decal# B. Facility Description (coot.) 5. BCI Construction 20 Loudonvill Road Name of General Contractor Address Albany 12204 518-426-3200 City/Town Zip Code Telephone Granite State Insurance 7252577 Contractors Workers Comp.Insurer 6. What is the size of this facility? Policy# 7200 Square Feet 11/04/03 Exp.Date 2 #of floors C. Asbestos Transportation and Disposal Transporter of asbestos-containing material from site to temporary storage site (if 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. 25 Silver Street Name of transporter Portland, CT 06480 (860)342-0667 City/Town Zip Code Telephone 3. N/A Note:Contractor must sign this form for DOS notification purposes Refuse transfer station and owner Address City/Town Zip Code 4. Turnkey Recycling & Environmental Enterprise Final Disposal Site location name 97 Rochester Neck Road Address NH 03839 State Zip Code Telephone Turnkey Recycling & Environmental Enterprise Owners Name Gonic City/Town (603)330-0217 Telephone 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. Notification BCI•9/02 Grace Mitchell Name Administrative Assistant Position/Title (413) 583-5500 Telephone Ludlow, MA City/Town co /a-b3 A . orized Signs l.r- 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?) ®Yes ❑No Asbestos Notification Form•Page 3 of 4