24 Asbestos Notification Form 2003 facility Description
f. Current or poor use of far,'r.
Rest er&UC E
2. R the tacilhy owner-acceded 'esidentl with 4 units or less3 Yes le No
3. Facility Owner.
rrceaCC'S MiteenE 2''/ !e)A2(> Sr
Name
M4 C/O CO /3-58914'86
kke AHPTati
anno>m
4 Facilt,s Owners O •Srle'Cn:ager.
/3-)/41
uneDal
5. General Contractor
Ace . Asbestos Pe m oval & 1n ulatIcr. 716 Rine 1-;eal7pra .Rd . .
Name _`-
Nort`rfield MA C'. 60 413 49R-0201
aolova reano.ae
J
237±)V
Granite State :ns . Co. vG971057P4 09/01/03
contactor.s woken como lnsore• :="Ne Eu Oat
6. What is the size of the facility°35-A70(sq to a (0 of floors)
ElAsbestos Transportation and Disposal
1. Transporter of asbestos-containing waste material from s:e'n temporary storage site Ql necessary)to final disposal site:
Ace Asbestos Removal T :nsulatinn 716 "ine
meadow Rd .
Name -
Northfield , ^:., 01760 413-498-0201
2. Transporter or asbestos-coda:meg waste maleral from rena:ab temporary sraage site to final disposal site
Waste alanacemect or 7T , Tnc . 203 Pic'cerirs Ft .
Portland CT 06480 860-342-0667
•
SII88f8oCTIOIu
t All sections alas
loim must 9e completed
in NOV to comply YAM
:he Department of
Environmental
Protection notitcation
requirements at 310 OMR
715 (fen working days
pncil nIXilralionIS
reqUired of any abatement
proJec :dM me
Department of Labor
and Industries
notilIWion iequir emelt6
of 453 CMF 612 ',ten
days prof notilcatrn rs
regw/ed of ANY
abatement pioieje3IPl
that!tree'!neat Of
sgu9'e feel.
2. SMmit Original FNm
To
Commonwealth of
Massachusetts
Asbestos Program
P.O.P.120087
8os1oe,MA 02111-
0087
3 This lqr,may be
used for not:prig fie
J S Eno onmeniai
Frmcaion Agency Region
1
at asbestos aermleionl
renovate oper2t,ors
saolen to NESIAPS LO
Oak
Commonwealth of Massachusetts
Asbestos Notification Form — ANF•001
13 Asbestos Abatement Description
Facl.uy location
II/elk res /OerLCC
-29 k"ard Jt
eff
tided-leapt 11114 6/0a0
6asemeat
h IISie.rolm,e aol ,e .ug elre/.n v a:.:
2. Is the facility occupied? t Yes = No
3 Asbestos Contractor
Ace \`:Int-ot `a
Na,e
actin's - -r.6Uiat
of `__.- .
C:N/lown
ieime/
4. On-Site Project Super/isorForeman
rr
c: ett col /'fcitt / termer
N° 767926
iephone
JUN 3 2003
on 7 t F. 1r t EI ^?Ea A' MPTOtirSOAin1OFHEALTH
Adarzss
—k??—02Lt_
1 eeplfrone
AS270245/AS70066
Pau& ui:Cenevl foie/
5. Pro ect Monitor
.av,par,c J . °resr flan 4 .:1.60
nave tor Gem,ae uu/
6. Asoestos Analytical Lab'.
Eu vi non rat ti t a 1 Sal in;; a Te 'ttor 3, COO 132 _.. .
3a so
(a l(a 03end sate i /7L3specilic work hours(Mon.-Fri.) d n- ye (Sat Sun } 1&
Z Pralect start tlSe� I —.
3O1L2K c,Flfl'h%GE ,:plate
mn(m C1t
Inea �rmnev�
6. What type of project is mis? Ic:¢le cne) __ ...
Note: Transfer
Stations must
compy with the
Solid Waste
Division regula-
tions 310 CMR
18.00
Note:Contractor
must sign this
form for DL!
notification
purposes
VNe+er
3. Refuse transfer station and owner (if applicable).
N/.'�
Nan
C.gnom ,• ,..
4. Final Disposal Site.
Turnkey Recycling & Fnvir Ent et arises, haste blymt of NH , Inc .
t P"JM Ne,ne
97 Rochester Slec'c Rd .
Addlen
(Eon ic
onnixi*
C_R39 603-330-0217
D
Certification
The undersigned hereby states. under the penalties of perjury.that he/she has read Me Commonwealth of viassacnuselis Regulations
for the Removal,Containment or Encapsulation of Asbestos,453 CMR fi 00and 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
Prim
rsin'rie
wrvd Shearer'
dv✓ 3 /30/o3
See Ashestos Removal
),(efS/ahrVL Insulation
716 Pine Meadow Rd .
Address
ReprPC nnny
Ofl
413-498-0201
Alsclow
T:orthfield , v,A 01360
rsne
Fee exempt (City,Town,district, municipal housing authority,owner-occupied residential of four units or less)7 yes ❑ no
Sticker (from front of form).
76, 79,v
,elw.o hem
Rev.6,92.
9. Describe the assedasaba.emet) ors 3 res to De used ,cvclel
�ru,: mr anrrem Omw
et—tio variable air pressure ,
01 work area / PEP", cac , HEPA
` filter respiratcr , 'xet asbestos
10. Is the lob being conducted , 1 indoors Ea outdoors 7
11. Tmal amount 01 each type of Asbestos Containing Materials(ACM)to De handled on pipes or ducts(linear ft.) c 55 or
aMer
senates (sq.,e'e C.1 RI 5 to be removed, enclasea or encapsulated_
]neansquare leer
P- beamP a.A Sre'Ce:231c;5 S e p'pe 'SJld lo/I
conegalH or layeseepaper pipe,nsualmc / insumlaating 5 cemenTt
Spray on hrepmming ,_ voweVsdaye,coatings
dclns.woven horns bamile taaro wall 00310.
or:N(please oesc
12. Describe the decontammatior,s)sten sl to be sea � oh a r _ �.
Con ']flit
t , ¢tit , , A. '✓ a-. for clean—up.
y�ter •.
.: .er , _5 _..
dsl omph with 31 CMR 7.15 and 453 CMR 5.14(2) gl
a . ilu. double sealed P° "'ohs
13. Dee�riba the .oniamerRahonld is�.._al me o
14. For :merger Asoestos ADalemec:.:pera..ons.the DE? and Do o9ficials 'to evaluated the emergency.
15. Do prevailing wage rates apply as pe' M.G_. c. 149. §25. 27,or27A-F to thisprdlect7 CC Yes ,4 No