60 Asbestos Notification Form 2008 i
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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