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60 Asbestos Notification Form 2008 i r' Portant: en filling out is on the 'outer,use the tab key love your ;or-do not the return [RUCTIONS Commonwealth[ Massachusetts a. Asbestos Notification Form ANF-001 • 100079813 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? a Yes ❑No b. Provide blanket decal number if applicable: 2. Facility Location: !RYE RESIDENCE a.Name of Facility northampton c.City/Town 3. Worksite Location: I sections of this •must be plated in order rmpy with 4 'notification irements of 310 2 7.15 5 the Division ccupational by(DOS) icalbn irements of 453 6.12 ese0 inf001ap.doc•1 6 GARAGE a.Building Name/Building Location MA d.State b Building# Is the facility occupied? p Yes ❑ No Asbestos Contractor: ACE ASBESTOS REMOVAL&INSULATION a.Name NORTHFIELD C.City/Town 101360 d.Zip Code AC000006 f.DOS License Number THOMAS SHEARER h.Facility CanladfPerson THOMAS R SHEARER a Name of On-Site Supervisor/Foreman 7. a.Name of Project Monitor RAYMOND J BRESNAHAN 8 9 ENVIRONMENTAL SAMPLING AND TESTING a.Name of Asbestos Analy&Cal Lab 11/5/2008 a.Project Start Date(mm/dd/yyyy) 7-5 c Work hours Mon-Fri. 10. a.What type of project is this? 11 ❑Demolition GI Renovation ❑ Repair ❑Other, please specify: a. Check abatement procedures: ❑ Glove bag ❑ Enclosure ❑ Cleanup Full containment 12. Is the job being conducted 0/02 ❑ Encapsulation ❑ Disposal only ❑Other, specify: Blanket Decal Number 60 CRESCENT ST b Street Address 01060 4135826800 e.Zip Code f.Telephone Number C. ng d.Floor e.Room 101 CROSS RD b.Address 4134980201 e.Telephone Number g. Contract Type: Written ❑Verbal SUPERVISOR i.Contact Person's Title AS070066 b.Supervisor/Foreman DOS Certification Number AM900294 b.Project Monitor DOS Certification Number AA000132 b.Asbestos AnalMMcal Lab DOS Certification Number 11/6/2008 b.E nd Date(mm/dd/yyyy) NA d.Work hours Sat-Sun. b.Describe DECEIVE OCT 1 5 2008 NORTHAMPTON BOARD OF HEALTH b.Describe Indoors? ❑Outdoors? Asbestos Notification Form•Page 1 of 3• Commonwealth .• • Massachusetts Asbestos Notification Form ANF-001 • 100079813 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 I a.Total pipes or ducts(linear ft) c.Boiler,breathing,duct,tank surface coatings S e Corrugated or layered paper pipe insulation 0 b.Total other surfaces(square fl) 40 g. Spray-on fireproofing i.Cloths,woven fabrics k.Thermal,solid core pipe insulation Lin.ft Lin.ft Lin.ft. S .ft Sq.ft. d.Insulating cement L Trowel/Sprayer coatings h.Transite board,wall board j.Other,please specify: Lin.ft. Lin.ft Sq.ft. I.Specify Lin.ft. Lin.ft. Lin.R Lin.ft. Sq.ft. Sq.ft. Sq.ft 14. Describe the decontamination system(s)to be used THREE CHAMBER DECON WITH WARM WATER SHOWER,TYVEK SUITS AND HEPA VAC 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): REWET ASBESTOS AND PACK IN DOUBLE, CABLED AND SEALED POLY BAGS 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: a.Name of DEP OFaia h.Title c Date(mu dd/yyyy)of Authorization e.Name of DOS Official g.Date(mm/ddyyyy)of Authorization d.DEP Waiver# DOS Official Title h.DOS Waiver# 17. Do prevailing wage rates as per M.G.L.c. 149,§26, 27 or 27A—F apply to this project? ❑Yes GI No B. Facility Description 1. Current or prior use of facility: 2. Is the facility owner-occupied residential with 4 units or less? GARAGE,STUDIO 4. RENNA PYE a.Facility Owner Name NORTHAMPTON c.City/Town 01060 d.Zip Code NA a.Name of Facility Owners On-Site Manager c.Cityrtown inf001ap doc•10/02 d.Zip Code GI Yes ❑No 60 CRESCENT ST b.Address 413-5824800 e.Telephone Number(area code and extension) b.On-Site Manager Address e Telephone Number(area code and extension) Asbestos Notification Form•Page 2 of 3 IG 14134980201 e.Telephone Number 1101 CROSS RD g.Address 'NORTHFIELD h.City/Town a:Transfer ions must ply with the d Waste Yon uletion0 310 R 19.000 ii11=a, ®o N MMO Mao _O _2 _a anIOOlap.doc•10/02 Commonwealf~if Massachusetts Asbestos Notification Form ANF-001 r 1100079813 Decal Number B. Facility Description (cont.) 5. ACE ASBESTOS REMOVAL AND INSULATIO a.Name of General Contractor NORTHFIELD c.City/Town 1NA f.Contractors Worker's Comp.Insurer 6. What is the size of this facility? 01360 d.Zip Code 101 CROSS RD b.Address 413-498-0201 1I e.Telephone Number(area code and extension) h.Exp.Date(mm/dd/yyw) 12 p.Policy Number 11700 a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site Of necessary): ACE ASBESTOS REMOVAL AND INSULATIO a.Name of Transporter !NORTHFIELD 01360 101 CROSS RD b.Address 4134980201 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. 1TRANSWASTE INC a.Name of Transporter IWALLINGFORD c.City/Town 06492 INA a.Refuse Transfer Station and Owner c.Ciry/Town 4. [BFI IMPERIAL LANDFILL a.Final Disposal Site Location Name 1PO BOX 47-11 BOGGS ROAD C.Final Disposal Site Address IPA e.State 13 BARKER DR b.Address 12032698300 d.Lp Cade a.Telephone Number I 1 b.Address d.Zip Code e.Telephone Number I [BROWNING FERRIS IND b.Final Disposal Site Location Owner's Name 1 [IMPERIAL d.CIN/rown 17246950900 g.Telephone Number 15126 f.Zip Code 1 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. THOMAS R.SHEARER a.Name [PRESIDENT c.PositioN1i0e Thomas R. Shearer b.Authorized Signature [10113/2008 d.Date(mMdd/vwv) IACE ASBESTOS REMOV f. Representing 01360 Zip Code Asbestos Notification Farm•Page 3 of 3