241 #14 Asbestos Notification Form 2003 Important:
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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