241 #15 Asbestos Notification Form 2003 Commonwealth of Massachusetts
Lif Asbestos Notification Form ANF-001
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor do not
use the return
key.
INSTRUCTIONS
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
of Occupational
Safety(DOS)
notification
requirements of
453 CMR 6.12
A. Asbestos Abatement Description
i. Facility Location:
Hampshire Heights Building 15
Name of Facility
Northampton
City/Town
Worksite Location:
Kitchen, Bathroom & 2od Floor Hall
MA
State
%Ilea
Please Enter%I lea 14
N2 767102
MAR 2 8 2003 ")
241 Jackson Street --
Street Address
01060 N/A
Zip Code Telephone
Building name,a,wing,floor,room.
2. Is the facility occupied? ❑ Yes ® No
3. Asbestos Contractor:
AccuTech Insulation &Contracting,
4.
5.
6.
2. Submit Original
Form to
Commonwealth of
Massachusetts 7.
Asbestos Program
PO Box 120087
Boston MA
02112-0087
Notification•9/02
100 State St., P.O. Box 376
Name
Ludlow, MA
City/Town
A0000005
DOS License
Scott Dunbar
01056
Zip Code
Address
(413) 583-5500
Telephone
Contract Type: ®Written ❑ Verbal
Estimator
Facility Contact Person
Brandon Besaw
Contact persons title
AS70407
Name of On-Site Supervisor/Foreman
To Be Determined
DOS Certification k
Name of Project Monitor
To Be Determined
DOS Certification k
Name of Asbestos Analytical Lab
03/27/03
Project Start Date
7 AM to 4 PM
DOS Certification k
04/15/03
End Date
N/A
Work hours Mon-Fri.
8. What type of project is this?
❑ Demolition
❑ Repair
Z Renovation
❑ Other, please specify:
Check abatement procedures:
Work hours Sat-Sun.
❑ Glove bag ❑ Encapsulation
❑ Enclosure ❑ Disposal only
❑ Cleanup ❑Other, specify:
® Full containment
10. Is the job being conducted: Z Indoors? ❑ Outdoors?
Asbestos Nofification Form•Page 1 of 4
As.
Commonwealth of Massachusetts
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:
400
pipes or ducts(linear fl) other surfaces(square ft)
Boiler,breaching,duct,tank surface /400
coatings lin.ft sq.ft
Corrugated or layered paper pipe /
insulation lin.ft sq.ft
Spray-on fireproofing lip.ft sq.tt
Cloths,woven fabrics Iln.it sq.ft
Thermal,solid core pipe insulation lin.ft sq.ft
Insulating cement
Trowel/Sprayer coatings
Transite board wall board
Other,please specify.
lin ft
lin ft
lin.ft
sq ft
sq ft
sq.ft
/
'in 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:
Bob Schultz
Name of DEP official Title
03/26/03 W085-03
Date of Authorization Waiver k
Gary Gaspar
Name of DOS official Title
03/27/03 03-141-NB
Date of Authorization Waiver k
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
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 Owner's On-Site Manager Address
Residential
City/Town
Notification•9/02
Zip Code Telephone
Asbestos Notification Form•Page 2 of 4
Commonwealth of Massachusetts
=tli= Asbestos Notification Form ANF-001
Note Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
7&71o0
Please Enter Decal#
B. Facility Description (cont.)
BCI Construction
5.
Name of General Contractor
Albany
City/Town
Granite State Insurance
20 Loudonville Road
12204
Address
518-426-3200
Zip Code
Telephone
7252577
Contractor's Worker's Comp. Insurer
6. What is the size of this facility?
Policy N
72,000
Square Feet
11/04/03
Exp. Date
2
p of floors
C. Asbestos Transportation and Disposal
Note:Contractor
must sign this lorm
for DOS notification
purposes
Notification•9/02
1.
Transporter of asbestos-containing material from site to temporary storage site (if necessary)to final
disposal site:
AccuTech Insulation &Contracting, Inc.
Name of transporter
Ludlow, MA 01056 (413) 583-5500
City/Town Zip Code Telephone
2. Transporter of asbestos-containing waste material from removal/temporary site to
100 State Street, P.O. Box 376
Address
3.
Waste Management N.E.E.T., Inc.
Name of transporter
Portland, CT
City/Town
N/A
06480
Zip Code
25 Silver Street
nal disposal site:
(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
Telephone
Turnkey Recycling & Environmental Enterprise
Owner's Name
Conic
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 Position/Title
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 Ludlow, MA
knowledge and belief. City/Town
Grace Mitchell
Name
Administrative Ass
(413) 583-5500
Telephone
Fee exempt(city,Town,district,municipal housing
L3-07V 03
orized Signature and Date
stant AccuTech Insulation &
Contracting, Inc.
100 State St P.O. Box 376
Address
01056
Zip Code
authority,owner-occupied residential of four units or less?) ®Yes ❑No
Asbestos Notification Form•Page 3 of 4
Commonwealt'f Massachusetts Ask
ti j Asbestos Notification Form ANF-001
Important:
When filling out
forms on the
computer.use
only the tab key
to move your
cursor-do not
use the return
key.
INSTRUCTIONS
1.All sections of
this form rust be
completed in order
to comply with
DEP notification
requirements of
310 CMR 7.15
and the Division
of Occupational
Safety(DOS)
notification.
requirements of
453 CMR 8.12
A. Asbestos Abatement Description
1. ,Facility Location:
Hampshire Heights Building 15
Name of Facility
Northampton
City/Town
Worksite Location:
Kitchen, Bathroom &2nd Floor Hall
MA
State
241 Jackson Street
iLzJ/03
Please Enter ecale
NQ 767105
llWE
MAR 2 8 200 IL
J
Street Address
01060
Zip Code
N/AL._..
Telephone
fdPTON BOARD OF HEALTH
Building name,x,wing,floor, room.
2. Is the facility occupied? ❑Yes ®No
3. Asbestos Contractor:
AccuTech Insulation &Contracting,
4.
5.
6.
2.Submit Original
Form to:
Commonwealth of
Massachusetts 7,
Asbestos Program
PC Box 120087
Boston MA
02112-0087
Notification•9/02
Name
Ludlow, MA
city/Town
AC000005
DOS License 4
Scott Dunbar
100 State St., P.O. Box 376
01056
Zip Code
Facility Contact Person
Dale Hardy
Address
(413) 583-5500
Telephone
Contract Type: ®Written ❑ Verbal
Estimator
Contact person's tie
AS71733
Name of On-Site SupervisorForeman
To Be Determined
Name of Project Monitor
To Be Determined
DOS Certification 0
DOS Certification A
Name of Asbestos Analytical Lab
04/08/03
Project Start Date
DOS Certification#
7 AM to 4 PM
Work hours Mon-Fd.
8. What type of project is this?
❑ Demolition
❑ Repair
® Renovation
❑ Other, please specify:
9. Check abatement procedures:
04/15/03
End Date
NIA
Work hours Sat-Sun.
❑ Glove bag ❑ Encapsulation
❑ Enclosure ❑ Disposal only
❑ Cleanup ❑Other, specify:
❑ Full containment
10. Is the job being conducted: ® Indoors? ❑ Outdoors?
Asbestos Notification Form•Page 1 of 4
,.
Commonwealt, of Massachusetts
Asbestos Notification Form ANF-001
Please nter Decal•
A. Asbestos Abatement Description (cont.)
11. Total amount of each type of Asbestos Containing Materials (ACM)to be removed. enclosed, or
encapsulated:
400
pipes or ducts(linear ft) )400 other surfaces(square ft) /
Boller,breaching,duct,tank surface Im ft sq.ft Insulating cement Iin.ft sq.ft
coatings
Corrugated or layered paper pipe Iin.ft 1
sq.ft sq.coatings link sq.ft
insulation
/ /
Spray-on fireproofing Iira It sq.ft Transits board,wall board lin.ft sq.ft
/ Ober ease specify:
Cloths,woven fabrics Iin.ft sq.ft p q Y
/ /
Thermal,solid core pipe insulation Iin.ft sq.ft Iin.ft sq.ft
12.-Describe the decontamination system(s)to be used: -
Seals criticals with 6 mil poly, wet down with amended water and remove in whole while area is under
negative pressure.
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 .city .
14. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
N/A
Nemec/DE. official - Title
Date of Authorization Waiver•
N/A
Name of DOS official Tttle
Date of Authorization Waiver•
15. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27.4—F apply to this project? ® 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' Facility Owner Name - - Address
Northampton 01060 413-584-4030
Cfty/Town Zip Coda Telephone
John Hite same as above
4' Name of Facility Owner's On-Site Manager Address
City/Town
Notification•9/02
Zip Code Telephone
Asbestos Notification Form•Page 2 of 4
Commonwealth of Massachusetts
sj Asbestos Notification Form ANF-001
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
71y l#
Please nter De al#
B. Facility Description (cont.)
BCE Construction 20 Loudonvill Road
5.
Name of General Contractor Address
Albany
Ciryrown
Granite State Insurance
12204
Zip Code
518-426-3200
Telephone
7252577 11/04/03
Contractor's Workers Comp. Insurer Polity# Exp. Date
6. What is the size of this facility?
72001 2
Square Feet #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
Cityrown 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 transponer
Portland, CT
Cifyrown Zip Code Telephone
3. NiA
Refuse transfer station and owner Address
06480 (860) 342-0667
City/Town Zip Code Telephone
4. Turnkey Recycling & Environmental Enterprise Turnkey Recycling & Environmental Enterprise
Final Disposal Site location name Owners Name
97 Rochester Neck Road Genic
Address City/Town
Note:Contractor
must sign this form
for DOS notification
purposes
Notification•9/02
NH
State
03639
Zip Code
(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.
Grace Mitchell
Name
Administrative Assistant
Postttorntle
(413) 583-5500
Telephone
Ludlow, MA
Cfy,Town
63'a5
J,411 r 3
horized Signature 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