160 Asbestos Notification Form 2006 mportant:
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100029088
Decal Number
FEB 2 7 230
A. Asbestos Abatement Description
a. Is this facility fee exempt-city, town, district, municipal housing authority, owner-occupied
residence of four units or less? ❑Yes F4 No
b. Provide blanket decal number if applicable:
2. Facility Location:
NSTRUCTIONS 3.
All sections of this
orm must be
ompleted In order
o comply with 4.
)EP notification
equirements of 310 5.
:MR 7.15
rid the Division
•f Occupational
;stet),(DOS)
totification
equirements of 453
:MR 6.12
6.
7.
8.
0 9
0
NORTHAMPTON AERONAUTICS
a.Name of Facility
NORTHAMPTON
c.City/Town
Worksite Location:
MEN'S 8 WOMEN'S BATHR
a Building Name/Building Location
Is the facility occupied? ❑Yes
Asbestos Contractor:
ACCUTECH INSULATION 8 CONTRACTING !!
a.Name
MA
d State
b.Building#
No
LUDLOW
c.City/Town
01056
d.Zip Code
AC000005
f.DOS License Number
Blanket Decal Number
160 OLD FERRY ROAD
It Fadlity Contact Person
HECTOR MANUEL SUAREZ GARCIA
a.Name of On-Site Supervisor/Foreman
ATC
a.Name of Project Monitor
SCILAB
a Name of Asbestos Analytical Lab
03/09/2006
a.Project Start Date(mm/dd/yyyy)
8:00-4:00
c.Work hours Mon-Fri.
o 10. a. What type of project is this?
Demolition F Renovation
❑ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
0
Z
C
O
❑Glove bag
❑ Enclosure
❑ Cleanup
❑J Full containment
❑ Encapsulation
❑ Disposal only
❑Other, specify:
12. Is the job being conducted: (% Indoors?
anf001ap.doc•10/02
b.Street Address
01060 j (413) 563-7139
e.Zip Code f.Telephone Number
c.Wing
d. Floor
e.Room
100 STATE STREET
b.Address
4135835500
e.Telephone Number
g. Contract Type: ❑Written
❑Verbal
i.Contact Person's Title
AS071103
b.Supervisor/Foreman DOS Certification Number
AA000005
b.Project Monitor DOS Certification Number
AA000162
b.Asbestos Analytical Lab DOS Certification Number
03/10/2006
b.End Date(mm(dd/yyyy)
N/A
d.Work hours Sat-Sun.
b.Describe
b.Describe
Outdoors?
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Asbestos Notification Form•Page 1 of 3
0
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
•
100029088
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM)to be removed, enclosed, or
encapsulated:
0
a.Total pipes or ducts(I':near ft)
c.Boiler,breaching,duct,tank
surface coatings
e.Corrugated or layered paper
pipe insulation
g Spray-on fireproofing
i.Cloths,woven fabrics
k.Thermal,solid core pipe
insulation
70 F
b. I dal other surtaces(square ft)
Lin.ft.
Lin.ft.
Lin.ft.
Lin.fl.
Sq ft.
Sq.ft.
Lin.ft.
Sq.ft.
Other,please specify.
Sq.ft. I.Specify
d.Insulating cement
f.Trowel/Sprayer coatings
h.Transits board,wall board
r
Lin.ft
Lin.ft
Lin.ft.
SS tSq a
Lin.ft
70
Sq.ft.
LINOLEUM
14. Describe the decontamination system(s)to be used:
TWO LAYERS OF 6 MIL POLY ON THE WALLS AND FLOOR WITH AN ATTACHED 3 STAGE D
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
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:
N/A
a.Name of DEP Official
_i I
c. Date(mm/dd/yyyy)of Authorization
N/A
e.Name of DOS Official
b Title
d.DEP Waiver#
f DOS Official Title
g Date(mm/dd/yyyy)of Authorization
o 17. Do prevailing wage rates as per M.G.L. c.
h.DOS Waiver#
49, § 26, 27 or 27A—F apply to this project? ❑Yes
No
o B. Facility Description
N
0
0
0
0
Z
1 Current or prior use of facility:
2. Is the facility owner-occupied residential with 4 units or less?
3.
COMMERCIAL
ROBERT BACON
a.Facility Owner Name
IWESTFIELD
c.City/Town
4 FALAN DZIALO
a.Name of Facility Owner's On-Site Manage_
d.Zip Code
101086
d.Zip Code
• anf001 ap.doe•10/02
c.City/Town
❑ yes R]No
P.O.BOX 699
b.Address
413-563-7139
e.Telephone Number area code and extension)
b.On-Site Manager Address
e.Telephone Number(area code and extension)
Asbestos Notification Form•Pa ea a 2
ate:Transfer
tations must
amply with the
did Waste
Iivision
:egulations 310
'.MR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1100029088
Decal Number
B. Facility Description (cant.)
5 IN/A
' a.Name of General Contractor
c Cltyrtown
d Zip Code
GRANITE STATE/ZIMMERMAN INSURANCE
f Contractor's Workers Comp.Insurer
6. What is the size of this facility?
b.Address
e.Telephone Number(area code and extension)
WC6929778
q.Policy Number
800
a.Square Feet
11/04/2006
h.Exp.Date(mm/dd/wvy)
1
b.Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos-containing material from site to temporary storage site Of necessary):
ACCUTECH INSULATION &CONTRACTING
a.Name of Transporter
LUDLOW
01056
1100 STATE ST. P.O.BOX 376
b.Address
(413) 583-5500
c.City/Town d.Zip Code e.Telephone Number
2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site:
3
4
RED TECHNOLOGIES,LLC
a. Name of Transporter
FARMINGTON
c.City/Town
06032
0.Zip Code
a.Refuse Transfer Station and Owner
c.City/Town
MINERVA ENTERPRISES INC
5 FOREST PARK DRIVE
b.Address
(860) 218-2428
e.Telephone Number
b.Addres
d.Zip Code _ e Telephone Number
a.Final Disposal Site Location Name
9000 MINERVA ROAD
c.Final Disposal Site Address
OH
e.State
44688
f.Zip Code
b.Final Disposal Site Location Owner's Name
WAYNESBURG
d.City/Town
11
g.Telephone Number
D. Certification
The undersigned hereby states, under the
° penalties of perjury, that he/she has read the
Commonwealth of Massachusetts regulations
f the R I 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
to the best of his/her knowledge and belief.
• anf001ap.doc•10/02
JUDY CROWLEY
a.Name
OFFICE MANAGER
C.Position/Title
(413) 583-5500
e.Telephone Number
rAu ` _iu E2
b-AU}nodzetl Signature
02/23/2006
d.Date(mmlddhyyv)
ACCUTECH INSULATIO
f.Representing
100 STATE ST. P.O.BOX 376
q.Address
LUDLOW
h.City/Town
1 101056
i Zip Code
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Asbestos Notification Form•Page 3 of 3