241 #3 Asbestos Notification Form 2003 Commonwealth L. Massachusetts
LiAsbestos Notification Form ANF-001
A. Asbestos Abatement Description
portant:
len filling out
its on the
neuter,use
y the tab key
nova your
sor-do not
the return
ISTRUCTIONS
All sections of
is form must be
)mpleted in order
I comply with
EP notification
:quirements of
10 CMR 7.15
nd the Division
f Occupational
afety(DOS)
otification
3quirements of
53 CMR 6.12 6.
1. Facility Location:
Hampshire Heights Building 3
Name of Facility
Northampton
City/Town
Worksite Location:
Kitchen, Bathroom &2ntl Floor Hall
241 Jackson Street
7Li974 c
Please Enter Decal
N= 769745
MA
State
Street Address
01060 N/A
Zip Code Telephone
Building name,#,wing,floor,room.
2. Is the facility occupied? ❑Yes ®No
3. Asbestos Contractor:
AccuTech Insulation & Contracting,
4.
5.
'.Submit Original
'orm to:
lommonwealth of
Aassachusetts 7
tsbestos Program
'0 Box 120087
3oston MA
12112-0087
Name
Ludlow, MA
City/Town
AC000005
DOS License#
Scott Dunbar
01056
Zip Code
Facility Contact Person
Dale Hardy
Name of On-Site Supervisor/Foreman
To Be Determined
Name of Project Monitor
To Be Determined
11 IJl 1 9 2003
01
100 State St
Address
(413) 583-5500
Telephone
Contract Type:
Estimator
Contact person's title
AS71733
DOS Certification#
J i
AMPTON BOARD OF REALTY I
T%x 376
®Written ❑Verbal
DOS Certification#
Name of Asbestos Analytical Lab
06/27/03
DOS Certification#
06/30/03
Project Start Date
7 AM to 4 PM
End Date
N/A
Work hours Mon-Fri.
8. What type of project is this?
❑ Demolition ® Renovation
❑ Repair ❑ Other, please specify:
9. Check abatement procedures:
❑ Glove bag
❑ Enclosure
❑ Cleanup
❑ Full containment
10. Is the job being conducted
Notification BCI•9/02
Work hours Sat-Sun.
❑ Encapsulation
❑ Disposal only
®Other, specify: VAT/Mastic
Indoors? ❑ Outdoors?
Asbestos Notification Form•Page 1 of 4
Commonwealth t.r Massachusetts
j Asbestos Notification Form ANF-001
Please Zr 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
En.ft sq.ft
/400
fin.ft sq.ft
lin.ft sq.ft
lin.ft sq.ft
lin.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
lia.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
damn it
14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
N/A
Name of DEP official
Date of Authorization
N/A
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? ®Yes ❑ No
B. Facility Description
1. Current or prior use of facility
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes ® No
3 Northampton Housin• Author 49 Old South Street
it Address
Facility Owner Name 413-584-4030
Title
Waiver#
Title
Waiver#
Residence
Northampton .
City/Town
John Hite —
4. Name of Facility Owners On-Site Manager
City/Town
Notification BCI•9/02
01060
Zip Code Telephone
same as above
Address
Zip Code Telephone
Asbestos Notification Form•Page 2 of 4
1e:Transfer
)lions must
mply with the
Aid Waste
vision
•gulations 310
AR 19.000
Commonwealth ur Massachusetts
Asbestos Notification Form ANF-001
70 Ns'
Please Enter Decal#
B. Facility Description (cont.)
BCI Construction 20 Loudonvill Road
Name of General Contractor Address
Albany 12204 518-426-3200
City/Town Zip Code Telephone
7252577
5.
6.
Granite State Insurance
11/04/03
Contractor's Worker's Comp.Insurer
What is the size of this facility?
Policy#
7200
Square Feet
Exp.Date
2
#of floors
C. Asbestos Transportation and Disposal
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:
25 Silver Street
1.
Waste Management N.E.E.T., Inc.
Name of transporter
Portland, CT 06480 (860)342-0667
City/Town Zip Code Telephone
3. N/A
Refuse transfer station and owner
Address
City/Town Zip Code Telephone
4. Turnkey Recycling & Environmental Enterprise Turnkey Recycling Reecycling & Environmental Enterprise
Final Disposal Site location name
97 Rochester Neck Road Gonic
Address City/Town
03839 (603)330-0217
NH
State
Zip Code
Telephone
Note:Contractor
must sign this form
for DOS notification
purposes
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
Notification BCI•9/02
Grace Mitchell ILL r II
Name u = 'zed Signatur and Date
Administrative Assistant AccuTech Insulation &
Position/rite 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 ❑No
Asbestos Notification Form•Page 3 of 4