41 Asbestos Notification Form 2008 Iithibili ; r . C OL HEYUH
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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
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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
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Asbestos Notification Form•Page 3 of 3