811 (rooms 120-123) Asbestos Notification Form 2008 Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100079172
Decal Number
A. Asbestos Abatement DescriptionDnicl al housing authority, owner-occupied
1. a. Is this facility fee exempt-city,town,district, P
residence of four units or less? SI Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location'.
MASSACHUSETTS HIGHWAY DEPARTMENT
a.Name of Faci
NORTHAMPTON
c.CayROwn
3. Worksite Location:
PHASE 7 ROOMS
a.Building Nam
this
fer
310
i
Blanket Decal Number
811 NORTH KING STREET
b.Street Address
1060
e.Zip Code
1.153
4. Is the facility occupied?
5 Asbestos Contractor:
ACCUTECH INSULATION&CONTRACTING II,
F'
b.Building It
Yes ❑No
a.Name
LUDLOW
CM
AC000005
f.DO License Number
KRISTEN WELLS
h Faali tyC tact Person
BRANDON E BESAW
6. a.Name of OrkSite Su•erosorlForemen
URS
7
a Nallle of Proecl Monitor
URS
a.Name f Asbestos
1210312008
=o
Pro ect Start Date
7:00-5:00
c.Work hours
on-Fri.
mmlddl
10. a.What type of project is this?
❑Demolition U Renovation
El Repair ❑Other,please specify:
11. a. Check abatement procedures:
o
GLL
=z
=C
01056 J
d Zip Code
Glove bag
❑Enclosure
0 Cleanup
Full containment
F'
❑Encapsulation
Disposal only
Other, specify'.
0
12. Is the job being conducted: S Indoors?
lap doc•10/02
(413)582-0523
f.Telephone Number
c 1Mng d.Floor
b
e.Room
100 STATE STREET
b.Address
4135835500
e.Telephone Number
g. Contract Type: GI Written Verbal
i.Contact Person's Title
AS070407
b.Su rvisorlForeman DOS Certification Num
AM061710
b.Pro ect Monitor DOS Cert ification Number
AA000175
Asbestos AnalN
1211212008
b.End Idtl
ical Lab DOS Certification Number
IA
d
Date mm
rFI �lFnl
■■,,�,, 'II-
(ii111•r
b.De
nbe
NORTHAMPTON BOARD OF HEALTH
CAULKING REMOVAL
b Describe
Outdoors?
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Asbestos Notification Form•Page I of 31.
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100079172
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
aola pipes or uct (linear )
c.Boiler,breaching,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
i.Cloths,woven fabrics
It Thermal,solid core pipe Lin fl Sq.insulation
14. Describe the decontamination system(s)to be used
SEAL CRITICALS W/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
ACM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEAL
6.14(2)(g)'.
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
Title
of Authorization d.DEPWaiver#
) cial Title
h.DOS Waiver#
d.Insulating cement
Lin.fi. Sq.ft.
f.Trowel/Sprayer coatings
Sft.
h.Transite board,wall board
Sq.ft
j.Other,please specify.
(TILE& MASTIC
I.Specify
Lin.ft
Lin.ft.
Lin.ft. ,53 ft
Lin.ft
Lin.ft
Lin.ft.
•
Sq.ft.
300
Sq.ft.
Sf tt_
1800
g.Date(mm/dtyyyy)of Authorization
17. 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?
MASSACHUSETTS HIGHWAY DEPARTMEN
3. Facth ry Owner Name
NORTHAMPTON
c.
Cry ca
KRISTEN WELLS
OFFICE SPACE
4.
lap doc•10102
tl.Zip Code
N fF ctty Owners On-Site Manager
City/Town
d.Zip Code
❑Yes • No
811 NORTH KING STREET
b.Address
1413-582-0523
e Telepb Number code and extension
.
L
On-Site Manager Address
•
413-743-3065
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa ea a 2 of 3=
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er
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the
310
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
'100079172
Decal Number
B. Facility Description (cant.)
IBURKE CONSTRUCTION
5. a.Name of Gener
'ADAMS
c.CW/Town
[COMMERCE &INDUSTRY
f.Contractors Workers Comp.Insurer
6. What is the size of this facility?
01220
d.Zip Code
16 RENFREW STREET
b.Address
413-743-3065
e.Telephone Number(area code and extension)
11/04)2008
h Exp.Date(mrwddyyyy)
'WC5312904
g.Policy Number
'30,000
a.Square Feet
2
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site(if necessary):
[ACCUTECH INSULATION & CONTRACTING
[100 STATE STREET
a.Name of Transporter O.Address
[LUDLOW (413) 583-5500
c.City/Town d.Zip Code e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
3.
01056
[RED TECHNOLOGIES
a.Name of Transporter
(PORTLAND
c.City/Own
06480
d.Zip Code
173 PICKERING STREET
b.Address
(860) 342-1022
e.Telephone Number
a.Refuse Transfer Station and Owner
c Cty/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
b.Address
[
' [44688
f Zip Cede
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
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.
ap doc-10/02
HEATHER R. CREPEAU
a.Name
ADMIN.ASSISTANT
C.Position/ritle
1(413) 583-5500
e.Telephone Number
b.Authorized 5 nature .SC(-- -------')�
109/30/2008
d.Date(mMddlyyyy)
'ACCUTECH
tin
100 STATE STREET
q.Address
[LUDLOW
h.City/Town
[
01056
i.Zip Code
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Asbestos Notification Form•Page 3 of 3