7 Project Revision & Asbestos Notification Form 2008 u
Is
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention -Air Quality
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
A. Facility Location
00066706
Decal Number
7 BARDWELL STREET
2.Street Address
NORTHAMPTON
3 City
4135840161
6.Telephone Number
B. Project Cancelled
u Check here if this project islwas cancelled.
et C. Project Dates
at
01/24/2008
re ct
tl
3.Latest Revised Stan Date �
r new
ur
D. Revised eJ Project Dates
01/2812008
Revised ldtllyyyy)
E. Other Project Revisions
l _ _
F. Revision History
pdrn.doc•rev.215104
MMA t
4.State
01124/2008
r .
2 End Date mm/dd
4.Latest Rev (
' 2 Revised End vyy)
2./28/20 Entl Date Date(m
RECIEEIVE
JAN 1 4 2008
0
NORTHAMPTON BOARD OF HEALTH
r►
Massachusetts Department of Environmental Protection
Bureau of Waste Prevention—Air Quality
..
100066706
Decal Number
Project Revision Notification
For Asbestos Notification ANF-001 and AQ 06
G. Certification
of
The undersigned hereby states,under the penalties of perjury,that he/she has read the CMCommonwealth 3f0
Massachusetts regulations for the Removal,Containment or Encapsulation of Asbestos,453
CMR 7.15, and that the information contained in this notification is true and correct to the best of his/her knowledge
and belief. ---i /
HEATHER . CREPEAU
1. Name ----'
OFFICE MANAGER
PositioNTitle
4. Re.resentin,
00 STATE STREET
6. Address
LUDLOW
7 CIty/Town
imdoc•rev.2/51114
Authona
$frffi
01/11/2008
3. Date mmld
(413) 583-5500
5. Tele.hone
AA
01056
8. Zip Code
IS (fu •
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100066706
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?Li Yes a No
b. Provide blanket decal number if applicable.
Blanket Decal Number
2. Facility Location:
SHEBEK PROPERTY
a.Name of Pad
NORTHAMPTON
c.City/Town
3. Worksite Location:
BASEMENT b,Building a.Building Name/Building Location
4. Is the facility occupied? 7 Yes L. No
f this
der
- b.Street Atld res _..
'.Nip �'i 01060 x(413)584-0161
d
e.Zip Code 1.Telephone Numbe
State
0
n 310 5. Asbestos Contractor:
IACCUTECH INSULATION 8 CONTRACTING II
a Name
of 453
IL DLOW _--- 101056
d.Zip Gotle'
c.c'i now ----
rl
AC000005
DOS License Number
JAMES BEADLE
h F Tty Golkact cerson
6 DOREY BESAW
a.Name o�So a^'isorlFOremg--�'---"I
IATC
T a.Name of P
ISCILAB
c $ Name ASbes os An mldcda YLYayb
0 9 Protect Start m e c 10112412008
o ect Monitor
—'
1
0 18:00-5:00 --------'J
c.Work flours Mon-Fri.
—-N
10 10. a.What type of project is this?
_'.. Demolition iL Renovation
Repair [ Other. please specify'.
11. a. Check abatement procedures:
o rl Glove bag 1 Encapsulation
"-1 Enclosure Cleanup Disposal only
o _ Other, specify
1L 7 Full containment
z Indoors? Outdoors?
Q 12. Is the job being conducted: 7 Indoors '_i
c Wing d Floor
1,100 STATE STREET
b.Atltlress
4135835500
e.Telephone Number
g. Contract Type: Written
e Roam
Verbal
i.Contact Person's Title
AS071928
b Su _rv_is_o_rtsmgman DOS Certification
b Pro ea Momtor DOS Certification Number —i
IAA000162
best bestos Anal Lab DOS Certification Number--�
0112412008
L---
b.End Dale mmldtllYYYY)—_-----'—
iN!A
0.Wok hours Sat-Sun.
101ap doc•10102
os NotlfiCatlen Form•Page 1 of 3
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
[100066706
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed, or
erica osulated: -
a. otal pipes or ducts(linear )
er su aces squa
d.Insulating cement
in fl. Sq. ft. —I
35
c.Boner,breaching,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g Spray-on fireproofing
f.Trowel/Sprayer coatings
Lin.ft__, 59�,
_,J l h Transile board,wall board
Lin ft ISgft
L�_� j.Other,please speciiy.
I.Cloths,woven fabrics Lin fl Sp fl
1125 IJ
in
k. elation solid core pipe Lin.ft Sq ft. I.Spec[
insulation
14. Describe the decontamination system(s)to be used.
(SEAL CRITICALS WI 6MIL POLY,ATTACH 3 STAGE DECONTAMINATION UNIT 8 INSTALL AIR 1,
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
614(2)(9): -- _
ACM TO BE DOUBLE BAGGED OR WRAPPED IN 6 MIL POLY AND DELIVERED IN A SEALED
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
•
c.Date(mm/ddlt#l)of Authorization
NIA — icial [tie___.
e.Name of Dial-- ---
h.DOS Waiver#
r. g.Date(mMdd/wyy)of Authorization 7 '-'YES
_m X26, 27 or 27A—F apply to this project.
E0 17. Do prevailing wage rates as per M.G.L. c. 149, §
=O B. Facility Description
(d.DEP Waiver#
.r (RESIDENCE
1. Current or prior use of facility.
2. Is the facility owner occupied residential with 4 units or less.
Yes
T. No
-" 73 MAIN STREET
SHE ___-- - —'--"_--
[PETER S
F rtv Owner Name [61602
AMHERST
4.
JAMES BEADLE -----
a.Name of FaciliYCwn_r's On-Site Manager_—__
b_Address __ _-- ------
1413-256-3442 _
e.Telephone Number_(area code and ew ens i
iron-Site Manager=ddress _ _---
'�413-256-3442
a City/Town
d.Zip Code e.Telephone Number(area code and extension)
Asbestos Notification Ram•Pa a 2 of 3
tap tloc•10102
I- .r
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100066706
Decal Number
B. Facility Description (cont.)
IC
do
=m
=o
1N/A
a.Name of General Contractor
c.City/Town
(COMMERCE&INDUSTRY
f.Contractor's Worker's Comp.Insurer
6. What is the size of this facility?
d Zip Code
b.Address
e.Telephone Number(area code and extension)
1WC5310868 1 111/04/2008
q.Policy Number i.Exp. Date(mMdd/Wyy)
1
2
12,000
a.Square Feet
b.Number offloors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary).'IACCUTECH INSULATION&CONTRACTING I 1100 STATE STREET
_ b.Address
a.Name of Transporter b.
1(413) 583-5500 .
LUDLOW d.Zip Code e.Telephone Number
C.GitylTOwn
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
(RED TECHNOLOGIES � 1173 DICKERING STREET _:
b.Address
PORTLANND
a.Name of Transporter 106480 1 1(860) 342-1022
c.DItVITOVm tl.Zi p I Code e.Telephone Number
—
I
a.Refuse Transfer Station and Owner b.Address
I
3.
c.CiryROwn d Zip Code e.Telephone Number__
4. IMINERVA ENTERPRISES INC __J I
a-Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name
19000 MINERVA ROAD 11 IWAYNESBURG
c.Final Disposal Site Atltlress ,
d.City/Town
IOH 1 1144688 1 L
e.State f Zip Code g.Telephone Number
-° D. Certification
WMN
The undersigned hereby states, under the
-° penalties of perjury,that he/she has read the
kr-
Commonwealth of Massachusetts regulations
for the Removal, Containment or
Encapsulation of Asoestos,453 CMR 6.00 ano
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.
=0
I ap.doc•10/02
(HEATHER R.CREPEAU
a.Name
;OFFICE MANAGER
c_Position/Title _-.-
!(413) 583-5500
e.Telephone Number
1100 STATE STREET
rg.Address
'b.Authorized nature -
101111/2008
d Date(mmltldlyyW)
IACCUTECH
f.Representing
LUDLOW 101056
h.Ciry,'TOwn i.Zip Code
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Asbestos Notification Form•Page 3 of 3