811 (rooms 101,103,201) Asbestos Notification Form 2008 ACCUTECH INSULATION 8 CONTRACTING It
o .
0 Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
Important:
Wien filling out
forms on the
computer,use
only the tab key
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INSTRUCTIONS
U
100079176
Decal Number
A. Asbestos Abatement Description
1. a Is this facility fee exempt -city,town, district, municipal housing authority, owner-occupied
residence of four units or less? ig Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
MASSACHUSETTS HIGHWAY DEPARTMENT
a.Name of Facility
INORTHAMPTON
c.City/Town
3 Worksite Location:
1.All sections of this
form must be
completed in order
to comply with 4
DEP notification
requirements of 310
CMR 7.15 5
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 6 12
7.
8.
0 9
0
0
z
C
PHASE 8 RMS 101, 103,201
a Building Name/Building Location
Is the facility occupied?
Asbestos Contractor:
MA
d.State
b.Building#
Yes ❑No
a.Name
LUDLOW
c.City/Town
01056
d.Zip Code
AC000005
f.DOS License Number
KRISTEN WELLS
Facility Contact Person
BRANDON E BESAW
a.Name of On-Site Supervisor/Foreman
URS
Blanket Decal Number
811 NORTH KING STREET
b.Street Address
01060
e Zip Code
c Wng
(413)582-0523
I.Telephone Number
d.Floor
a Room
100 STATE STREET
O Address
4135835500
e.Telephone Number
g. Contract Type:
Written ❑Verbal
i Contact Person's Title
AS070407
a.Name of Project Monitor
URS
a.Name of Asbestos Analytical Lab
12/18/2008
a.Project Start Date(mm/ddlyyyy)
7:00-5:00
c.Work hours Mon-Fn
10 a What type of project is this?
❑Demolition Renovation
❑Repair ❑Other, please specify:
11. a. Check abatement procedures:
❑ Glove bag
❑ Enclosure
❑ Cleanup
Full containment
❑ Encapsulation
❑ Disposal only
n Other, specify:
b.Supervisor/Foreman DOS Certification Number
AM061710
b.Project Monitor DOS Certification Number
AA000175
b.Asbestos Analytical Lab DOS Certification Number
12/30/2008
b.Bid Date
mm/dd/
�Ii111 iifl�
b.De-!•! V
NORTHAMPTON BOARD OF HEALTH
CAULKING REMOVAL
b De cribe
12. Is the job being conducted: [3 Indoors? U Outdoors?
anfo0lap doe•10/02
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Asbestos Notification Form•Page 1 of 3
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100079176
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or
encapsulated:
0
a.Total pipes or ducts(linear fl)
c.Boiler,breaching,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
I.Cloths.woven fabrics
k.Thermal,solid core pipe
insulation
2100
Total other surfaces(square ft)
Lin.ft.
Lin.ft.
Lin ft
Lin.ft
Sq.ft.
Sq ft.
Sq.ft.
Ss.
TILE & MASTIC
Sq.fl. I.Specify
Lin.ft.
d.Insulating cement
T Trowel/Sprayer coatings
h.Transite board,wall board
j.Other,please specify:
14. Describe the decontamination system(s)to be used:
Lin.ft. So ft.
300
Lin.ft. Sq.ft.
Lin.ft.
1800
Lin.ft. Sq.ft.
SEAL CRITICALS WI 6MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNIT&INSTALL AIR
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(9):
ACM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
'NIA
a.Name of DEP Official
c Date(mmltltl/yyyy)of Authorization
IN/A
e.Name of DOS Official
b.title
d.DEP Waiver#
cial I i
g.Date(midd/yyyy)of Authorization h.DOS Waiver#
o 17 Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project?[]Yes ❑ No
o B. Facility Description
O 1 Current or prior use of facility:
0
OFFICE SPACE
2. Is the facility owner-occupied residential with 4 units or less?
3. a.Facility Owner Name
o 'NORTHAMPTON
MASSACHUSETTS HIGHWAY DEPARTMEN
°
Z
c.City/Town
01060
d Zip Code
4' a.Name of Facility
KRISTEN WELLS
er
On-Site Manager
❑Yes
No
811 NORTH KING STREET
b.Address
413-582-0523
e.Telephone Number(area code and extension)
b.On-Site Manager Address
ant001ap.doc•10/02
c.City/Town
d Zip Code
413-743-3065
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa ea a 2
>~ -
17: Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
Note:Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
100079176
Decal Number
B. Facility Description (cont.)
BURKE CONSTRUCTION
5_ a.Name of General Contractor
ADAMS
C.City/Town
01220
d.Zip Code
COMMERCE& INDUSTRY
f.Contractor's Worker's Comp.Insurer
6. What is the size of this facility?
6 RENFREW STREET
b.Address
413-743-3065
e.Telephone Number(area
WC5312904
q.Policy Number
30,000
a.Square Feet
code and extension)
11104/2008
h.Exp. Date(mn ddlyyyy)
2
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
ACCUTECH INSULATION&CONTRACTING
a.Name of Transporter
'LUDLOW
c.City/Town
01056
d.Zip Code
2. Transporter of asbestos-containing waste material
100 STATE STREET
b.Address
(413) 583-5500
e.Telephone Number
from removal/temporary
RED TECHNOLOGIES
a.Name of Transporter
PORTLAND
c.CiN/Town
06480
d.Zip Code
a.Refuse Transfer Station and Owner
c.City/Town
4. 'MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
'9000 MINERVA ROAD
c.Final Disposal Site Address
'OH
e.State
d Zip Code
44688
f Zip Code
e to final disposal site:
173 PICKERING STREET
b.Address
(660) 342-1022
e.Telephone Number
b.Address
e.Telephone Number
b.Final Disposal Site Location Owners Name
WAYNESBURG
d.City/Town
g.Telephone Number
D. Certification
The undersigned hereby states,under the
penalties of perjury,that he/she has read the
C Ith f M h tt g I t
for the Removal, Containment or
Encapsulation of Asbestos,453 CMR 6.00 and
310 CMR 7.15, and that the information
t 'n d in this notification is true and correct
to the best of his/her knowledge and belief.
anf001ap.doc•10/02
HEATHER R. CREPEAU
a.Name
ADMIN.ASSISTANT
C.Position/Title
(413) 583-5500
e.Telephone Number
• 'Ms.
Authorized ignature
109/30/2008
d.Date(mm/dd) y)
ACCUTECH
Representin
100 STATE STREET
q.Address
LUDLOW
h.City/Town
01056
Zip Code
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Asbestos Notification Form•Page 3 of 3 U