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1 Asbestos Notification Form 2006 Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. 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 P E ci l s(c A ? FQ j e -f iDa-1--ce Go To Top 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 Go To Top 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/