61 Asbestos Notification Form 2002 Note:Transfer
Station must
comply with the
Solid Waste
OMelon regalia
Sus JIGChM
Inc
Mole:Contactor
most sign this
Ions lot DLI
notification
purposes
o Facility Description
1. Current or prior use(acuity:
Residence
2. Is the tardily owner-occupied resmemial with 4 units or tea?A Yes UNo
3. Facility Owner
Sheryl Hall 61 Nonomrk Street
Nan mm
Florence 01062 f413) 586-4867
awn. a Cot P m
4. Facility Owner's On-Site Manager:
N/A
name
Wow
5. General Contractor:
N/A
acMe
AS=
Ch/Ton
Aram Nana n
Hartford Underwriters Insurance #764X381301 06/09/03
Confronts Warners Comp.kart? raw. W.oar
What is the size of the facility?.X (sp II).X )l al floors)
0 Asbestos Transportation and Disposal
1. Transporter al ashe stonontaining waste material from site to temporarydomesie/if necessary)lo lm l diWSal elite:
Service Transport Group, Inc. 28 Privilege Street
Nan AMOS
Woonsocket RI 02895 (401)766-1824
osssan prat NI**.
2. Trampoder al asheaiosanufnlag waste malarial M1Om remahtempary Skagit site to Rana disponi alp:
N/A
. Alarm
cnno.e
3. Refuse transfer station and owner(1f applicable)
N/A
Mani
pore
Amer
4. Final Disposal Site:
Greenridge Reclamation
Ln,eo.*me
Landfill Road
Republic Waste Service Inc.
pawl pp.
Mean
Scottsdale PA 15683 (724) 887-9400
Nno.•
uCertification
II COP
Mmm
The undersigned hereby stales,under the pealties of perjury,that helhe lus read the commonwealth of Massachusetts Reputations
for the Removal,Containment or Encapsulation of Asbestos,453 CYR 6.10 and 310 CUR 715.and Tut the Information contained in
this notification is true tine correct to his/her knowledge and helfel.
Kathleen A. Sullivan
PM Warne
President
le et 77,,.s 08/31/02
lain/Sloan oar
Mercury Technical Services,Inc. (508) 755-1701
Iumomrin. MArmNy Pryew
210 Park Avenue # 306 Worcester,MA 01609-2246
Add® Ern Star
Fee exempt(City,Town,district,municipal housing authority,owneruaupiSd afdenfial of bar units or less? Mes m No
Sticker r(from Iron(of form):
F7 S5081
Ink
Commonwealth of Massachusetts
Asbestos Notification Form—ANF-001
Asbestos Abatement Description
Facility location:
Hall
a
INSTRUCnoxs rim,
I.NI settlom elthi Inn Florence, MA
mw comMelsd rayase
odv b tmeplymLMa Basement
pefagnmttl Mat,,the wmm location?eoumny raw,/,.
Pro cb nW ma.Clow.cant
P18stlmed'AimSm Is The taclIlly Occupied?Pa Yes ❑ No
equirementol NO CMR
requirement days
PAX MaitentiOa I 3. Asbestos Contractor:
pmjsadaod the mPN
projnlu l Me Mercury Technical Services, Inc 210 Park Avenue N 306
Isd nd roles bra m, naNv
m0leaublo
eolificabooredulrements Worcester, MA 01609-2246
flan
MAU aPalli21Mn nhne.n brw
MnMaeNPxedmM
liaindafpal AC ocean/ 0 annaOW(i
IGMmmlpnlaClaWr wraewl rwnwrwlrlRMeap
weal.SQ. a
Kona Mlf. On-Site Project Supervisor/Foreman:
61 Nonotuck Street
01062
7550814'
rb Coa
(413 586
SEP gK � -
NO iTHAMPTON BOARD OF HMi,f i
(508) 755-1701
2.SUbmf origins!farm
It
CaeomYM al
Ilissmamalts
ASIAN Preps
A0J,17981
Irosbe,114 02112.
IOU
Mona NI. Lehr
seam
Project Monitor:
Samuel N.Cohen
.Mama
5. Asbestos Analytical Lab:
AS 72898
Meer
ou CawMrw/
AM 53995
an CwVftntrov/
3.Ibis hammy be
trial lneotlryApm Envirotest Laboratory AA 000128
U.S.Enafmaeotll Name DPI Publication/
PtmNm Agency Region
1 W asbestos damllhoN 7. Project slave date l)yu/pzend date p9/u/e2speolllcatioe workhoun(Mon-Fri) RAM-SPM (Sal.Sun.)
mnonbm wagons
mbpslloNESRAPS(40
CH Subpart M). E. What type of project is this? (circle one): demommn nplr Cr nnbo7 amrtmpar)
9. Describe the asbestos abatement procedures to be used(plrtlef: 4.aM Ppm eenI, hill co almen: Nmup
encapsulation disposal wily other(nplaln) rfnl
b neg.air
For DNS pv0.}
dockaW
Renmf Nn
REIN
PundNanewmed
10. Is this job being conducted lia Indoors ❑outdoors y
11. Total amount of each type of Asbestos Containing MMerlals(ACM)10 be bulled on the pipes or dusts(linear N.) 95 or other
surfaces(square n.) 100 to be removed,enclosed or encapsulaled:
lineal/sgaala lee(
Buller,branching,awl.line sedans meals /WC Memel,senaun WO lmnllon _/_
mpaleb or layered paper pipe insulation 95 / Imblel/g mown, /
apnya0 Pre p(tellnp _l_ Itoireirtprarer cmWp.. _l_
cloths.woven Maw... /_ MOM Mani..will boa /
ulmr fpinre cescrlbel /
12. Describe the decontamination system(s)to be used:
A decon will be set up allowing workers to decontaminate before leaving.
13. Describe Mecontainerizationdisposal methods to comply with 310 CMR 2.15 now CMR 6.14(2)(g):
Asbestos will be placed in double 6ML poly bags,completely saturated sealed,
and disposed of in a certified landfill.
14. For Emergency Asbestos Abatement Operations,the Wand ON officials who evaluated the emergency:
Name dl Of?Pflinal
Date of AUmorltalon
Name of OLI OXItla)
Dale elAUmorinben Waiver
15. Go prevailing wage rates apply as per M.G.L.C.149.§25.27,or 27A-F to this project? 0 Yes GCMG
erctuy geckithaiJero.,•cee, gala
Leading the way in Environmental Quality
210 Park Avenue•#306
Worcester, MA 01609
Telephone(800)231-0964
FAX(800)920-9609
SPECIAL NOTIFICATION
Regarding Scheduled
Asbestos Abatement
To Whom It May Concern:
Mercury Technical Services,Inc.will be actuating an asbestos abatement procedure at
the address listed on the Form ANF-001 which has been enclosed.The project dates and
hours have been indicated on line 7.Our scope of work on this project includes the
removal and/or encapsulation of asbestos containing materials.As an environmental
contractor,Mercury Technical Services, Inc. strictly adheres to all federal,state,and local
regulations that pertain to Mese materials.
Let Nis letter be probative of Mercury Technical Services, Inc.having notified you of our
intended presence at the aforementioned address and the scope of work on Nis
project.Any situation requiring your response or services will be brought to your attention
immediately.Please contact us if you have any questions,or if we may be of service.
Sincerely yours,
Mercury Technical Services,Inc.
encl./copy of DEP/OL&WD notifications