119 Asbestos Notification Form 2003 S
Commonwealth Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description
1. Facility Location:
Vogel Residence
Name of Facility
Northampton
City/Town
Worksite Location:
Basement
Building name,#,wing,floor,room.
2. Is the facility occupied? E Yes
MA
State
119 Arch Sreet
Street Address
01060
Zip Code
�/ 070(0
Please Enter Decal#
N2 767090
413-253-3839
Telephone
❑No
3. Asbestos Contractor:
AccuTech Insulation & Contracting,
Name
S Ludlow, MA
City/Town
'be AC000005
rder DOS License#
n
if
3n
31
of
final
Scott Dunbar
Facility Contact Person
Brandon Besaw
4. Name of On-Site Supervisor/Foreman
N/A
5. Name of Project Monitor
N/A
6. Name of Asbestos Analytical Lab
th of
1s 7.
gram
87
06/02/03
Project Start Date
7 AM to 4 PM
Work hours Mon-Fri.
8. What type of project is this?
❑Demolition
❑Repair
01056
Zip Code
® Renovation
❑Other, please specify:
9. Check abatement procedures:
❑ Encapsulation
p Disposal only
p Other, specify:
Glove bag
❑Enclosure
❑Cleanup
❑Full containment
10. Is the job being conducted
n•9/02
MAY 2 1 2003
- AMPTCN BOARD OF HEALTH
100 State St., P.O. Box 376
Address
(413)583-5500
Telephone
Contract Type: ®Written ❑Verbal
Esitmator
Contact person's title
AS70407
DOS Certification#
DOS Certification#
DOS Certification#
06/02/03
End Date
N/A
Work hours Sat-Sun.
® Indoors? ❑ Outdoors?
Asbestos Notification Form•Paget of 4
Commonwealth Massachusetts
Asbestos Notification Form ANF-001
7&7ogo
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:
150
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
En.ft sq.ft
lin.ft sq.ft
lin.ft sq.ft
150/
Fin.ft sq.ft fin.ft sq.ft
other surfaces(square ft)
Insulating cement
Trowel/Sprayer coatings
Transite board,wall board
Other,please specify:
lin.ft sq.ft
lin.ft sq.ft
tin.ft sq.ft
12. Describe the decontamination system(s)to be used:
Seal criticals with 6 mil poly, pre-clean, lay drop cloth and remove using the negative pressure
qlovebag method.
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 cite
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,
B. Facility Description
1. Current or prior use of facility:
2. Is the facility owner-occupied residential with 4
Allen Vogel
3. Facility Owner Name
Northampton 01060
City/Town Zip Code
same as above
4. Name of Facility Owner's On-Site Manager
Title
Waiver#
Title
Waiver#
§ 26, 27 or 27A—F apply to this project? ❑Yes® No
Residence
City/Town Zip Code
m•9/02
units or less? ® Yes ❑ No
119 Arch Street
Address
413-253-3839
Telephone
Address
Telephone
Asbestos Notification Form•Page 2 of 4
ie
10
As flA
Commonwealth Massachusetts
Asbestos Notification Form ANF-001
C
Pw go
Please En er Decal#
B. Facility Description (cont.)
5.
Teagno Construction
Name of General Contractor
Amherst
City/Town
Granite State Insurance
Contractors Worker's Comp.insurer
6. What is the size of this facility?
PO Box 2054
Address
01004 N/A
Zip Code Telephone
7252577
Policy#
1700
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 (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 Address
Refuse transfer station and owner
City/Town Zip Code
4. Turnkey Recycling &Environmental Enterprise
Final Disposal Site location name
97 Rochester Neck Road
Address
NH 03639
State Zip Code
Telephone
Turnkey Recycling & Environmental Enterprise
Owner's Name
conic
City/Town
(603)330-0217
Telephone
actor
ris form
tification
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
in•9/02
Grace Mitchell
Name
Administrative Assistant
Poeifion/Title
(413) 583-5500
Telephone
Ludlow, MA
City/Town
authority,owner-occupied residentia
5-kn-63
ill 140
prized Sign re and Date
AccuTech Insulation &
Contracting, Inc.
100 State St, P.O. Box 376
Address
01056
Zip Code
I of four units or less?) El Yes ❑No
Asbestos Notification Form•Page 3 of 4