1 BLDG 26C & Connect Asbestos Notification Form 2008 • Important:
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INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100077438
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? 4 Yes ❑No
b. Provide blanket decal number if applicable:
2. Facility Location:
FORMER NORTHAMPTON STATE HOSPITAL
a.Name of Facility
Northampton
C.City/own
3, Worksite Location:
1.All sections of th s
form must be
completed in order
to comply with 4.
DFP notification
requirements of 310
CMR 7.15 5.
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 6.12
BUILDING 26C &CONNECT
a.Building Name/Building Location
MA
d.State
b.Building#
Is the facility occupied? ❑Yes ❑No
Asbestos Contractor:
AIR QUALITY EXPERTS INC
a.Name
ATKINSON
C.City/Town
03079
d.Zip Code
AC000167
f.DOS License Number
Blanket Decal Number
1 PRINCE STREET
b.Street Address
01060
e.Zip Code
c.Wing
Telephone Number
d Floor
e Room
123 HALL FARM ROAD
b Address
6038946465
e.Telephone Number
g. Contract Type: ❑Written ❑Verbal
h.Facility Contact Person
GERALD WHITE
6. a.Name of OnSite Supervisor/Foreman
N/A
7. a.Name of Project Monitor
8
9
I.Contact Person's Title
AS000782
b.Supervisor/Foreman DOS Certification Number
N/A
a Name of Asbestos Analytical Lab
9/11/2008
a.Pra'ect Start 0
TAM-5PM
to mmrddf
11
c.Work hours Mon-Fri.
O 10 a What type of project is this?
❑ Demolition ❑ Renovation
❑ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
o ❑Glove bag r, Encapsulation
❑ Enclosure ❑ Disposal only
Cleanup ❑Other, specify:
❑ Full containment
0
z
• 12. Is the job being conducted: j Indoors? Z Outdoors
■ anfoo1ap.doc-10/02
0
b.Project Monitor DOS Certification Number
b.Asbestos Analytical Lab DOS Certification Number
10/17/2008
b.E nd Date(mm/ddi yyyy)
N/A
d.Work hours Sat-Sun.
b.De
D
scribe
NORTHAMPTON BOARD OF HEALTH
Asbestos Notification Form•Page 1 of 3
SEP p 2008
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100077438
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or
encapsulated:
8938 241
a Total pipes or duds(linear ft)
c.Boiler,breaching,duct,lank
surface coatings
e.Corrugated or layered paper
pipe insulation
g.Spray-on fireproofing
Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
b.Total other surfaces(square H)
Lin.ft.
Lin.ft.
Lin ft
P
Lin.ft.
12250
Lin.ft.
240
Sq.fl.
Sq.ft.
Sq ft
1
S
Sq
14. Describe the decontamination system(s)to be used
d.Insulating cement
f.Trowel/Sprayer coatings
h Transite board,wall board
j.Other,please specify'.
Lin.ft
Lin.ft.
Lin
ft.
6688
Sq.fl.
Sq.ft.
Sq.ft
CAULK& GLAZrD3S !CI (jPbYtS
I.Specify 5
3-CHAMBER 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 Officia
b.Title
c Date(mSdd/yyyy)of Authorization
d.DEP Waiver it
e.Name of DOS Official
f.DOS Official Title
g.Date(mm/dd/yyyy)of Authorization h.DOS Warier#
° 17. Do prevailing wage rates as per M.G.L.c. 149,§ 26, 27 or 27A-F apply to this project? El Yes❑ No
° B. Facility Description
0 1 Current or prior use of facility:
0
0
LL
Z
FORMER HOSPITAL
2. Is the facility owner-occupied residential with 4 units or less?
3.
MASS DEVELOPMENT
a.Facility Owner Name
DEVENS
c.City/Town
ALAN DELANEY
01434
d.Zip Code
4' a.Name of Facility Owner's On-Site
❑Yes
No
33 ANDREWS PARKWAY
b.Address
978-784-2900
e.Telephone Number(area code and exension)
133 ANDREWS PARKWAY
b.On-Site Manager Address
anger
DEVENS
anf001ap doc•10/02
c.City/Town
01434
d Zip Code
978-784-2900
e.Telephone Number(area code and extension)
Asbestos Notification Form•Page 2 of 3
Note'.Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19 000
0
0
0
IL
Z
C
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100077438
Decal Number
B. Facility Description (cont.)
5. a Name of General Contractor
c.City/Town
d Zip Code
b.Address
e Telephone Number(area cod and extension)
L Contractor's Workers Comp.Insurer
6. What is the size of this facility?
q.Policy Number
a Square Feet
h.Exp.Date(mm/dd/yyyy)
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:
(SERVICE TRANSPORT GROUP
3
4
a Name of Transporter
IBRISTOL,PA
c.City/Town
J
19007
d.Zip Code
Refuse Transfer Station and 0 n
c.City/Town
MINERVA ENTERPRISES INC
a.Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
d.Zip Code
PO BOX 2132
b Address
8779999559
e.Telephone Number
b Address
OH
a State
44688
f.Zip Code
e.Telephone Number
b.Final Disposal Site Location Owner's 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
t - d th' ff t t d t
to the best of his/her knowledge and belief
• anf001ap doc•10/02
CHRISTOPHER THOMPS
a.Name
(PRESIDENT
c Position/Title
6038946465
e.Telephone Number
Christopher Thompson
b.Authorized Signature
08/27/2008
d.Date mm/dd/
AIR QUALITY EXPERTS
I Representing
AAA
23 HALL FARM ROAD
q.Address
!ATKINSON
h.City/Town
03811
Zip Code
Asbestos Notification Form•Page 3 of 3 El