241 #5 Asbestos Notification Form 2003 Commonwealth o. Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description
1. Facility Location:
Hampshire Heights Building 5
Name of Facility
Northampton MA
City/Town State
Worksite Location:
Kitchen, Bathroom &2na Floor Hall
Building name,#,wing,floor, room.
2. Is the facility occupied? ❑Yes E No
3. Asbestos Contractor:
AccuTech Insulation & Contracting,
Name
Ludlow, MA
City/Town
AC000005
DOS License#
Scott Dunbar
Facility Contact Person
Dale Hardy
4. Name of On-Site Supervisor/Foreman
To Be Determined
5. Name of Project Monitor
To Be Determined
6' Name of Asbestos Analytical Lab
al
of
7
IM
07/02/03
Project Start Date
241 Jackson Street
Street Address
01060
Zip Code
01056
Zip Code
Pleas nter Del#0
N4 769746
N/A
Telephone r�
LS
0V
jup4 nl 92003
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#
DOS Certifcation#
DOS Certification#
07/03/03
7 AM to 4 PM
Work hours Mon-Fri.
8. What type of project is this?
❑ Demolition
❑ Repair
E Renovation
❑ Other, please specify:
9. Check abatement procedures:
❑ Glove bag ❑ Encapsulation
❑ Enclosure ❑ Disposal only
❑ Cleanup E Other, specify:
E Full containment
10. Is the job being conducted: E Indoors? ❑Outdoors?
End Date
N/A
Work hours Sat-Sun.
VAT/Mastic
Asbestos Notification Form•Page 1 of 4
CI •9/02
Commonwealth 1,1 Massachusetts
Asbestos Notification Form ANF-001
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
lin.ft sq.ft
/400
fin.ft sq.ft
lin.ft sq.ft
fin,ft sq.ft
Tin,ft sq.ft
900
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:
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
dump site
14. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
N/A Title
Name of DEP official
Date of Authorization
Waiver#
N/A ue
Name of DOS official
Date of Authorization
15. Do prevailing wage rates as per M.G.L. c. 149,§ 26, 27 or 27A—F apply to this project? Z Yes ❑ No
Waiver#
B. Facility Description
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 Owners On-Site Manager Address
Residence
cityITown
CI•9/02
Zip Code Telephone
Asbestos Notification Form•Page 2 of 4
e
10
Commonwealth or Massachusetts
Asbestos Notification Form ANF-001
r769Q7c1(49
Please Enter Decal#
B. Facility Description (cont.)
BCI Construction
5.
20 Loudonvill Roa
Name of General Contractor
Albany
City/Town
Granite State Insurance
12204
Zip Code
Address
518-426-3200
Telephone
7252577
Contractors Worker's 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
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. 25 Silver Street
Name of transporter
Portland, CT
City/Town
3. N/A
06480
Zip Code
(860)342-0667
Telephone
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
:tor
s form
ication
Telephone
Turnkey Recycling & Environmental Enterprise
Owner's 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.
Fee exempt(city,Town,district,municipal housing
Grace Mitchell
Name uth•rized Signe - and Date
Administrative Assistant - AccuTech Insulation &
Position/Title Contracting, Inc.
(413)583-5500 100 State St, P.O. Box 376
Telephone Address
Ludlow, MA 01056
City/Town Zip Code
authority,owner-occupied residential of four units or less?) �Yes 0 No
Ifs ' AI .. ; _
BC'•9/02 Asbestos Notification Form•Page 3 of 4