1 BLDG 26D Asbestos Notification Form 2008 Imoorfant:
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INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100077439
Decal Number
A. Asbestos Abatement Description
a. Is this facility fee exempt-city,town, district, municipal housing authority, owner-occupied
residence of four units or less? t7 Yes ❑ No
b. Provide blanket decal number if applicable:
2. Facility Location:
1 All sections of tbls
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR 715 5.
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 612
0
0
U-
7.
a.
9 a.Project Start Date(mmrdd/yyyy)
FORMER NORTHAMPTON STATE HOSPITAL
a.Name of Facility
Northampton
c City/Town
Worksite Location:
BUILDING 26D
a.Building Name/Building Location
MA
d.State
b.Building#
Is the facility occupied? ❑Yes t7 No
Asbestos Contractor:
AIR QUALITY EXPERTS INC
a.Name
ATKINSON
c.City/Town
03079
d Zip Code
AC000167
f.DOS License Number
h.Faulity Contact Person
GERALD WHITE
a.Name of On-Site SupervisorForeman
N/A
a.Name of Project Monitor
N/A
a.Name of Asbestos Analytical Lab
09/11/2008
Blanket Decal Number
1 PRINCE STREET
b.Street Address
01060
7AM-5PM
a Work hours Mon-Fri.
e Zip Code
c.Wing
f Telephone Number
d Floor
e.Room
23 HALL FARM ROAD
b.Address
6038946465
e.Telephone Number
g. Contract Type'.
Written ❑Verbal
i.Contact Person's Title
AS000782
b Supervisor/Foreman DOS Certification Number
b.Protect Monitor DOS Certification Number
b.Asbestos Analytical Lab DOS Certification Number
10/17/2008
b Bid Date(mmlddlyyyy)
1 N/A
10 a What type of project rs this?
Demolition ❑ Renovation
❑Other, please specify:
❑Repair
11. a. Check abatement procedures:
Glove bag
❑ Enclosure
IJ Cleanup
Full containment
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
z
12. Is the job being conducted: ',Z Indoors?
• anf001ap.doc•10/02
d.Work hours Sat-Sun.
b Describe
p�
L S U E W E
f�LL SEP 1 0 2008
b.Describe
71 Outdoors?
NORTHAMPTON BOARD OF Nrnl7N
Asbestos Notification Form• I
Page age of 3•
CICommonwealth of Massachusetts
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0
0
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C
Asbestos Notification Form ANF-001
•
100077439
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or
encapsulated:
5219
a.Total pipes or ducts(linear ft)
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
8780
Tot al other surf aces(square ft)
Lin.ft.
Lin.ft.
250
Sq ft
Lin.ft
Lin.ft.
1875
Lin ft.
Sq.n.
S9_ft.
S n
Sq ft
14. Describe the decontamination system(s)to be used:
d.Insulating cement
f.Trowel/Sprayer coatings
h.Transite board,wall board
Other,please specify:
Lin.It
Lin.fl.
Lin ft
Sq.ft.
Sq.ft.
8530
Sq.ft
CAULK,TILE,LI
Specify
3 STAGE DECON
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
WET 2 LAYER POLY BAGS
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a.Name of DEP Official
c.Date(mm/dd/yyyy)of Authorization
e.Name of DOS Official
b.Title
d DEP Waiver#
f.DOS Official Title
g-Date(mm/dd/yyyy)of Authorization h DOS Waiver#
17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project?
SI
Yes ❑ No
B. Facility Description
1 Current or prior use of facility:
2.
3
FORMER HOSPITAL
Is the facility owner-occupied residential with 4 units or less?
rAASS DEVELOPMENT
a.Facility Owner Name
DEVENS
c.City/Town
ALAN DELANEY
01434
d Zip Code
❑Yes
No
33 ANDREWS PARKWAY
b.Address
a.Name of Facility Owners On-Site Manager
DEVENS 01434
anf001 ap.doc•10/02
c.City/Town d.Zip Code
978-784-2900
e.Telephone Number(area code and extension)
33 ANDREWS PARKWAY
b.On-Site Manager Address
1:978-784-2900
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa e
CHRISTOPHER THOMPd
Note Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19 000
oak
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100077439
Decal Number
B. Facility Description (cont.)
5.
a.Name of General Contractor
c.City/Town
d Zip Code
f.Contractor's Workers Comp.Insurer
6. Vvhat is the size of this facility?
b Address
e.Telephone Number(area cod and extension)
q.Policy Number
h.Exp.Date(mm/dd/yyyy)
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):
a.Name of Transporter
c.City/Town
d Zip Code
b.Address
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
3
4
SERVICE TRANSPORT GROUP
a.Name of Transporter
BRISTOL,PA
c.City/Town
19007
d.Zip Code
a Refuse Transfer Station and Owner
C.City/Town
d.Zip Code
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
OH
e State
44688
f Zip Code
PO BOX 2132
b.Address
(877)999-9559
e.Telephone Number
b.Address
e.Telephone Number
b.Final Disposal Site Location Owner's Name
WAYNESBURG
d.City/Town
g.Telephone Number
o D. Certification
N
The undersigned hereby states, under the
o penalties of perjury,that he/she has read the
o Commonwealth of Massachusetts regulations
f r 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.
°
2
anf001 ap.doc•10/02
a.Name
PRESIDENT
c.Position/ritle
(603)894-6465
e.Telephone Number
b.Authorized Signature
08/27/2008
d.Date(mm/dd/rn,v)
AIR QUALITY EXPERTS
f.Representing
23 HALL FARM ROAD
q Address
[ATKINSON
h.City/rown
03811
Zip Code
Asbestos Notification Form•Page 3 of;