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INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
;100037180
Decal Number
j1r .
(@ 1 > i
AUG 3 0 zuUd
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? Nj Yes j No
-'
b. Provide blanket decal number if applicable:
2. Facility Location:
3.
1.All sections of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR7.15 5.
and the Division
of Occupational
Safety(DOS)
notification
requirements of 453
CMR 6.12
7.
8.
O 9.
;NORTHAMPTON STATE HOSPITAL
a.Name of Facility
!Northampton j AMA
�c.City/Town d.State
Worksite Location:( r\0_3 , )`-`X
(TH
a.Building Name/Building Location b.Building#
Is the facility occupied? ❑Yes I!I No
Asbestos Contractor:
Blanket Decal Number
1 PRINCE ST
b Street Address
in-01060 J ,(978)772-6340
e.Zip Code F.Telephone Number
c.Wing
e.Room
;AIR QUALITY EXPERTS INC
a.Name
['SALEM
c.City/Town
;AC000167
;03079
d.Ziacode
f.DOS License Number
40 LOWELL RD UNIT 1
b.Address
6038946465
e.Telephone Number
g. Contract Type: ;L'l Wdtten ❑Verbal
h.Facility Contact Person
GERMAN POSADA ZINIGA
a.Name of On-Site Supervisor/Foreman
AMMAR DIEB
a.Name of Project Monitor
N/A
a.Name of Asbestos AWaI ;cal
ai Project Start Date(m d/yyyy)
• 7AM-5PM
c.Work hours Mon-Fn.
i.Contact Persons Title
AS032579
b.Suoervisor/Forenat DOS Certification Number
AA000177
b.Project Monitor DOS Certification Number
N/A
b.Asbestos Analytical Lab DOS Certification Number
;11/01/2006
b.End Date(mmfddljlyyy)
1
o 10 a What type of project is this?
o ice,Demolition Es Renovation
• Repair P Other, please specify:
11. a. Check abatement procedures:
0
0
IL
z
C
^'Glove bag
D Enclosure
LS leanup
Z Full containment
Encapsulation
Disposal only
Ej Other, specify:
d.Work hours Sat-Sun.
b.Describe
b.Describe
12. Is the job being conducted: ,r1JJ Indoors? [I Outdoors?
anf001ap.doc•10/02
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Asbestos Notification Form•Page 1 of 3
•
frea) Ask
Commonwealth of Massachusetts
LiAsbestos Notification Form ANF-001
;100037180 —J
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed,enclosed,or
encapsulated:
125300 1 18000
a.Total pipes or ducts(linear ft) lbTo(aTother surrTuare Ili
c.Boiler,breaching,duct,tank 11800 I i 1 1
surface coatings Lin.ft. 3q.ft. Lin.ft.
e.Corrugated or layered paper
pipe insulation
d.Insulating cement
f.Trowel/Sprayer coatings
h.Transits board,wall heard
g.Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
20000 I
Lin.ft. Sq.ft.
F 1 l..______J
Lin.ft. Sq.ft.
SVft J.Other,please specify
1, I I WNDWS,VAT,MST
Lin.ft. Sq.ft. I.Specify
14. Describe the decontamination system(s)to be used
Lin,fL
Lin.ft
13500
Lin.h.
1000
Sq.ft.
116000
Sq.ft.
1000
113 CHAMBER DECON
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (9):
NET 2 PLY POLY
16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency:
a.Name of DEP Official
b Title
c.Date(mm/dd/yyyy)of Authorization
d.DEP Waiver#
e.Name of DOS Official f.DOS Official Title
g.Date(mm/dd/yyyy)of Authonzation h.DOS Waiver#
o 17. Do prevailing wage rates as per M.G.L. c. 149,§26,27 or 27A–F apply to this project? 'x[j Yes Li No
o B. Facility Description
o 1 Current or prior use of facility:
!STATE HOSPITAL
2. Is the facility owner-occupied residential with 4 units or less? ❑Yes _j! No
!MASS DEVELOPMENT , 11 PRINCE ST
3. is_Facility Owner Name
o 'NORTHAMPTON i i
o £&ity/Tawn d.Zip_code
a.Name of Facility Owners On-Site Manager
Z
b.Address
1
e.Telephone Number(area code and extension)
b.On-Site Manager Addres
• c.City/Town
I anf001ap doc•10/02
d Zip Code
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa ea a 2
LAsbestos Notification Form ANF-001
Commonwealth of Massachusetts
Jots:Transfer
nations must
:omply with the
iolid Waste
/vision
Regulations 310
;MR 19.000
1100037180
Decal Number
B. Facility Description (cont.)
S&R CORP
6' a.Name of General Contractor
LOWELL
c.City/Town
d.Zip Code
J
1706 BROADWAY
b.Address
e Telephone Numberjarea code and extension)
r 1
f.Contractor's Workers Comp.Insurer
6. What is the size of this facility?
q.Policy Number h.Exp.Date(mm/tltl/yvyy)
I �
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):
FAIR QUALITY EXPERTS
a.Name of Transporter b.Address
r
c.City/Town
J
U
d.Zip Code
e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
3
[SERVICE TRANSPORT GROUP
a.Name of Transpoder
[BRISTOL
c.City/Town
9007
d.Zip Code
P0 BOX 2132
b.Address
(B77)999-9559
e.Telephone Number
a.Refuse Transfer Station and Owner
L I
c.City/Town d.Zip Code e.Telephone Number
4. A&L SALVAGE INC
a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name
11225 STATE ROUTE 45 [LISBON
c.Final Disposal Site Address d.City/Town
OH 144432
e.State f.Zip Code g.Telephone Number
b.Address
It
o D. Certification
The undersigned hereby states,under the
o p Iles 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 715,and that the information
contained in this notification is true and correct
to the best of his/her knowledge and belief.
0
0
LL.
Z
Q
anf001ap.doc•10/02
';CHRISTOPHER THOMPS(
a.Name
(PRESIDENT
c Position/Title
1(603)894-6465
e Telephone Number
40 LOWELL RD
.g Address
;SALEM
h.City/Town
b.Authorized Signature
:08/09/2006
d.Date(mm/tltl/ww)
;AIR QUALITY EXPERTS
T Representing
`03079
i Zip Code
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Asbestos Notification Form•Page 3 of 3
(603) 894-6465
(800) 621-1189
(603) 894-7044 FAX
c-n®c %.„(uulitJ 1Jlsp/i1 COI 1111..
r. �► Asbestos Removal
40 Lowell Road, Unit 1 tcesidential-Commercial-Industrial
Salem, NH 03079 AirQualityExperts @AQENH.com
August 9, 2006
Northampton Health Department
23 Service Center Road
Northampton, MA 01060
Dear Sir:
Enclosed please find a copy of notification sent to the state for an Asbestos
Abatement Project.
The job will take place on-08f24106.1)84�'�6 — ///O)/V,6
Project: Northampton State Hospital
I Prince Street
Any questions concerning this matter should be directed to my attention.
Sincerely,
C-1t0
Christopher Thompson
President
/e° V t §/r/ //,ye e/