712 Asbestos Notification Form 2003 AWA
Facy 0esctiption
1. Current or prior use of facility:
(ZCSI DEh1C L
2. Is the facility owner-occupied residential with 4 units or less? $ Yes 0 No
3. Facility Owner:
-E2 +- (,cfceen Re[kncUZL 7 ( -6YI(IkC1C Rol
Nm
Mims
�c(d-YYM FELn in / 416 4e $4.: 930
CWIem Mande reone
4. Facilhy's Owner's On-Site Manager:
WA
Mew Reef
Cf fno.n
5. General Contractor:
Ace Asbestos ..Removal. b,._.Insulation 716 Fine Meadow Rd.
Nme Address
Amen MeMe
Northfield MA 01360
413 498-0201
nyao.,, np coe res.
Granite State Ins . Co. WC8510584
09/01/03
Conbbrors workers Comp Insurer Pew I
6. What is the size of the facility?_30Yo9sq fqc"? (t of floors)
f+p.Date
Asbestos Transportation and Disposal
1. Transporter of asbestos-containing waste material from site to temporary storage site(if necessary)to final disposal site:
Ace Asbestos Removal & Insulation 716 Pine Meadow Rd .
Northfield, MA
6410,,m
01360 413-498-0201
➢p cote Telephone
2. Transporter of asbestos-containing waste material from removal/temporary storage site to final disposal site:
Waste Management of CT, Inc . 203 Pickering St .
Mane
Portland
CT 064Rl
Pee_ano ncce
AUCTIONS
dices al this
a be completed
o comply with
artment of
mental
ion notilkation
rent of 310 CMR
n working(lays
fli ariM is
folanraaatenCnf
and the
meat of Labor
It atria
ion requirements
1MR6,12 (ten
101 noblratlm 5
1 oIANY
ante ged crater
-a Iirear or
feel
me Original Fc
iomsaallh of
achualts
In Program
.120087
is MA 02112-
is Imm may be
ar notilnn9 the
nvuanmentai
lion Agency Region
;bales demolniaN
anon operations
a to NESHAPS(40
mmonwealth of Massachusetts
Asbestos Notification Form — ANF-001
CIAsbestos Abatement Description
1 Faclbry location
?cd, 15cee 1-CS ldew 7th �rlci �
Addree,
-41 ,amp { n FI.Al
tom
LCSc . ∎
h9W m f■e w/.offal Lath LUJI0/4 ndlre./ reJI9.ll:ar.WOO
2. Is the taciaty occupied? AS Yes LE No
3. Asbestos Contractor:
Ace Asbestos Removal
&wise
0 lei(yr. ())
201/J08
-5930
T M N
FEB - 32003
' AMPTON BOARD OF NEAtmN
insulation 716 Pine AteaHbw rc
AC 000006
C(LLCenm/
4. 0n-Site Project Supervisor/Foreman:
Fd Shearer/Ton Shearer
tele
5. Proles; Monitor.
".resnahan
R°CeSS
01.'50
novae
LAIC t-t(
co,iun the t.nrennnoai
qi a_n4P-.Q207
terepme
A 570245/A 570066
ou eea kaliad
Av16 C4
al CanI?cav,r/
AsdeStos Analytical Lab:
Environmental Sapling S Testing AA000132
O(ilen/amn/ [[5O 0
rune Z b r y3 (Sal Sun.) n
7 Project start date Ar�On nd Gate 5t)ir C Apecific work hours(Mon.-Fri-)��
update
om/1 NOW) teat
P0°"p0°n system
wnn t°ne of omled is this? (circle one)'. Oil/oh/WI
Note:Transfer
Stations must
comply iWm the
SoId Waste
ONiston regula-
tions 310 CMR
18.00
Note:Contractor
must sign this
form for Old
notification
purposes
tlry/row
3. Refuse transfer station and owner Of applicable):
N/A
Name
dpnae /Whom
Address
etn/rgM rn rA1P Telephone
4. Final Disposal Site:
Turnkey Recycling S Envir . Enterprises, Waste Mgnt of NH, Inc.
ImIAn Nam
97 Rochester Neck Rd .
LM"ei NLnP
Mfrs
Gonic NH- 03839
Warr /,rode
603-330-0217
telephone
D
Certification
The undersigned hereby states, under the penalties of perjury,that he/she has read the Commonwealth of Massachusetts Regulal
for the Removal.Containment or Encapsulation of Asbestos.453 CMR 6.00 and 310 CMR 7.15.and that the information contains
this notification is true and correct to the best of his/her knowledge and belief.
Edwards Shearer
PfMAbik
� �2iSID F.NI
f7
Au., ipnaure
.Ace Asbestos Removal
S Insulation
PosalaVinle
716 Pine Meadow Rd .
I)30/03
Os9
413-498-0201
aepesenrnq rele$ooe
Northfield , MA 01360
As CiPy/TUwn Zip n+h
Fee exempt(City.Town.district,municipal housing authority,owner-occupied residential of four units or less)? yes ❑
Sticker a(from front of form):
7379 )
Ira only
Ale
WWW TC
Oa
Rev.6/92.
0. Describe the asbestos abatement procedures to be used (circle): clove at mawave variable<ble
damp
set—up variable air pressure,
mneriWmam/ poly work area ,HEPA vac ,HEPA
filter respirator , wet asbestos
10. Is the lob being conducted A indoors outdoors?
11. Total arnou nt oteach type of Asbestos Containing Materials(ACM)to be handled on pipes or ducts(linear ft.) i`i0 wgther
surfaces (square e.) Yl c to be removed, enclosed or encapsulated.
Im ea rIsquare feet
to Jet,freacmrvy,duo.lane coo/ace coalmgs me mo, so core pipe u6Naripn __
ccrruga;ed or uyerza Pape'pipe msulalon / inmGpng cement -... -
3DmYpn fireproofing / IroweVSpayer coat'SS_.
cloths.woven,pia _____J UarSite OOtq wall Data.. —. --1
aUer(pPase JeYnbp /
12. Qescrine the becortammation systems)to be used 3 c h a rc e r d e c 0 ri u ni t w 1 th wa rm
sa ter sholrer, tyve'c suets , Y.E9A vac Car clean—up.
13. beset-10e tthe containerization/disposal methods to comply with 310 CMR 7 15 and 453 CMR 6.14(2)(g)
asbestos & sac': in labelled double sealed poly 'bags
xore re nos al Eroc. e.i t e
14. For Ei set;easy Asbestos Abatement Operations,the DEP and DL',officlais who evaluated the emergency
brie
corer/
one
/
15. Do pressing wage rases apply as per M&1 c 149, § 26, 27,or 27A-r to this project? ❑ Yes 'j No