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41 Asbestos Notification Form 2008 Iithibili ; r . C OL HEYUH PI W S : Il - , y i a Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100073031 Decal Number Important: Men filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. INSTRUCTIONS 1.Al sections of this form must be completed in order to comply with DEP notification requirements of 310 CMR 715 5. and the Division of Occupational Safety(DOS) notification requirements of 453 CMR 612 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'/ _i Yes 7 No b. Provide blanket decal number if applicable: Blanket Decal Number 2. Facility Location: RENTAL PROPERTY a.Name of Facility NORTHAMPTON c.City/Town 3. Worksite Location: !BASEMENT .41 CONZ STREET b.Street Address 1MA 101060 !(413)567.8183 '. el.State e.Zip Code f.Telephone Number a.Building Name/Building location b.Building# 4. Is the facility occupied? 7 Yes No Asbestos Contractor: 'ACE ASBESTOS REMOVAL AND INSULATIOi a.Name !NORTHFIELD '101360 c City/royal d.Zip Code AC000006 1. f.DOS License Number '..TOM SHEARER h.Facility Contact Person ',THOMAS R SHEARER a.Name of On-Site Supervisor/Foreman RAYMONDJ BRESNAHAN 7. a.Name of Project Monitor ENVIRONMENTAL SAMPLING&TESTING 8 a.Name of Asbestos Analytical Lab 9 06/23/2008 a.Protect Start Date(mm/ddtyyyy) TA-613 c.Work hours Mon-Fri. 10 a What type of project is this? ° Si Demolition 7 Renovation 11 Repair ] Other, please specify: 11. a. Check abatement procedures: o _J Glove bag n Encapsulation o I Enclosure _j Disposal only a ] Cleanup L Other, specify: J'. Full containment Z a 12. Is the job being conducted: 7, Indoors? [Jl Outdoors? G.Wing d.Floor e.Room 1716 PINE MEADOW ROAD b.Address 4134980201 _ e.Telephone Number g. Contract Type: ':✓I Written Verbal 'SUPERVISOR i.Contact Person's Title .AS070066 _— D.Supervisor/Foreman DOS Certification Number IAM900294 b.Project Monitor DOS Certification Number AA000132 b.Asbestos Analytical Lab DOS Certification Number 107/0312008 b.End Date jmm/ddtyyyy) NA d.Work ho b.Desa be anf001ap doc•1D/02 Go To Top Asbestos Notification Form•Page 1 of 3 ° Commonwealth of Massachusetts Asbestos Notification Form ANF-001 100073031 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or encapsulated: 240 120 a.Total pipes or ducts(linear ft) ETotafother surfaces(square ftt c.Boiler,breaching,duct.tank • 1120 tl.Insulating cement surface coatings Lin.fl. _ Sq.ft. Lm fl Sq fl e.Corrugated or layered paper 240__ f.Trowel/Sprayer coatings Lm ft Sq ft. pipe insulation Lin.ft. S9 fl r g.Spray-on fireproofing Lin ft Sq.fl. — h.Transite board,wall board Lin_ft Sq.ft._ i.Cloths woven fabrics Lin fl _._ Sq fl 1.Other please specify:,--..____ Lin.ft Sg_fl_— K Thermal,solid core pipe ' • insulation Lin.fl. Sq.R. I.Specify 14. Describe the decontamination system(s)to be used 'THREE CHAMBER DECON WITH WARM WATER SHOWER,TYVEK SUITS 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,LABELLED,AND SEALED POLY BAGS. 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: a.Name of DEP Official b.Title c.Date(mmldd/yyyy)of Authorization d.DEP Waiver# e.Name of DOS Official 1.DOSal 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? I_',Yes _! No ° B. Facility Description 0 0 =Q 1 Current or prior use of facility: 2. Is the facility owner-occupied residential with 4 units or less? r Yes r,. No 'RENTAL RESIDENTIAL ,JERRY BOUCHER ' '.164 CRESTVIEW CIRCLE a.Fadlity Owner Name b.Address ELONGMEADOW '.01106 ,413-3353640 c City/Town d Zip Code a Telephone Number(area code and extension) 'NA . . 4. __ ___ a.Name of Facility Owner s OnSite Manager b.On Sfle Manager Address. u City/Town tl.Zip Code e.Telephone Number(area code and extension) Asbestos Notfication Form•Pa a 2r1, of 3 anloOlap.doc•10/02 Commonwealth of Massachusetts P Asbestos Notification Form ANF-001 rte Transfer ations must mply with the Aid Waste vision .yulations 310 NR 19.000 n N 1100073031 Decal Number __ B. Facility Description (cont.) IACE ASBESTOS REMOVAL& INSULATION a Name of General Contractor NORTHFIELD 'i01360 c.City/Town d.Zip Code GRANITE STATE INS CO f.Contractors Workers Comp.Insurer 6. What is the size of this facility? ;716 PINE MEADOW RD b.Address 1,413-498-0201 e.Telephone Number(area code and extension) IWC6381497 I !09/0112008 rq.Policy Number h Exp.Date pemrdd/ yy).. '..2100 12 a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): r716 PINE MEADOW b.Address 1(413)498-0201 e.Telephone Number ACE ASBESTOS REMOVAL&INSULATION a.Name of Transporter NORTHFIELD 101360 c.City/Town d-Zip Code 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: 'TRANSWASTE INC 3 BARKER DRIVE a.Name of Transporter b.Address WALLINGFORD 06492 1(203)269-6300 c.City/Town d.Zip Code e Telephone Number r- 3. ',NA E a.Refuse Transfer Station and Owner b.Address c.City/Town d.ZJfl Code 4. BFI IMPERIAL LANDFILL J a. Final Disposal Site Location Name 1P0 BOX 47-11 BOGGS ROAD c.Final Disposal Site Address [PA 115126_ e State -_-- f.Zip Code e.Telephone Number [BROWNING FERRIS INDUSTRIES b.Final Disposal Site Location Owner's Name IMPERIAL d.City/Town 1(724)695-0900 g.Telephone Number D. Certification The undersigned hereby states,under the o penalties of perjury,that he/she has read the o 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 o to the best of his/her knovAedge and belief. LL Z C I anf001ap.doe•10/02 THOMAS R SHEARER a.Name I PRESIDENT c.Position/Dile 1(413)498-0201 e.Telephone Number 716 PINE MEADOW b.Authorized Signature 0610412008 d Date(mm/dd/vWv) ACE ASBESTOS REM. f Resenting q.Address 1 NORTHFIELD 'i01360 It City/Town i.Zip Code Go To Top Asbestos Notification Form•Page 3 of 3