421 N Main St Asbestos Abatement 7-8-20 #100329724Lam
4
AerErwtronmsntai
PO BOX 929
NOR.THBORO, MA, 01532
ereg@Aerotecasbestosremoval.com
PHONE: 978-375-9534 FAX: 508-393-3365
ATT : BOH
Fax : 413-587-1.221
FROM: Greg Harding
DATE: 6/812020
PAGES:
L'd 99£££6£809 oeloaey utd6Z LOZOZ9Zunr
EDWARD T KOLODZIEJ
a. Name of Project MonRor
9 ATCGROUPSERVICES INC
a. Name of Asbestos Analytical Lab
10.
7/0/2020
a. Project $!art Date (MM1DD1YYYY)
ANIM1905
L----
& DLS Certification
AA000005
b. DLS Certification ti
I
7/10/2020
b. End Date (NIMIDD/YYYY)
5AM 9PM 5AM 9PM
c, VVork Hours- Monday Through Friday--- d. Work Hours - Saturday &
11.. What type of project is this?
r a. Demolition g b. Renovation r— c. Repair r d. Other -Please Specify:
Paeo I of
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Massachusetts Department of Environmental Protection
1100ii29724
BWP .AQ 04 (ANF -001)
q
As'b
sYos Project #�
-
Asbestos Notification Fonn
j-`
roject Revision
i
ject Cancellation
A. Asbestos Abatement Description
1. Facility Location:
NORTHAMPTON VAMC
421 N MAIN ST
Instructions 1. All
a. Name of Facility
b. Street Address
suctions of this form
NORTHAAIFTON MA
01053 4136444040
must be completed In
order to comply with C. Ciry/Town d. State
o. Zip Code L Telephone
MassDEP notification
JOSEE GOLDIN
COTAR
requirements of 310
—
CMR 7.15 and g• Facility Contact Person Name
h. Facility Contact Person Tide
Department of Labor
Worltzite Location:
BLDG#1 RM 2160,1265D,
Standards (DLS)
--------
nogliication
t Builtling Name, Wing, Floor, Room, et
.
requirements of 453
2. Is the facility occupied? Ir a. Yes r b, No
CNIR 6.12
3. Is this a fee exempt notification (city, town, district,
municipal housing authori
, state facility, or
owner -occupied residential property of four units
or less)? R a. Yes r' b. No
k1assDEP Use Only
4. Blanket Permit Project Approval, if applicable:
Usla Received
Approval ID #
5. Non -Traditional Asbestus Abatement Work Practice
Approval,
if applicable:
Approve! 10 #�
b. Asbcstos Contractor.
AERO TECH EN\4RONM5tiTA-
163 RICE AVE
a. Name
b, Address
t ��
NORTHBCRCUGH MA
01532 °763759534i
a CityTown � � d. State
e. Zip Code I. Telephone
AGOOD921
h. Contract Type: w 1, Written
r 2. Verbal
g. DLS License #
7 ANDERSON MARTINEZ
-�
A8002444
a. Name of Contractors On -Site Supervisor/Foreman
bi DLS Cert!ficatlon
EDWARD T KOLODZIEJ
a. Name of Project MonRor
9 ATCGROUPSERVICES INC
a. Name of Asbestos Analytical Lab
10.
7/0/2020
a. Project $!art Date (MM1DD1YYYY)
ANIM1905
L----
& DLS Certification
AA000005
b. DLS Certification ti
I
7/10/2020
b. End Date (NIMIDD/YYYY)
5AM 9PM 5AM 9PM
c, VVork Hours- Monday Through Friday--- d. Work Hours - Saturday &
11.. What type of project is this?
r a. Demolition g b. Renovation r— c. Repair r d. Other -Please Specify:
Paeo I of
e, d 9g££E6££0s oat o.lav wd6Z' l OZOZ BZ unr
Massachiisetts Department of Environmental Protection ".l0 I"32972 4
�,- — WP � Q 04 (ATNF'—OOT.)
1 Asbestos Nati cation Form lis �esto6 Project it
f rojectRevision
i roject Cmlecilation
A. Asbestos Abatement Description: (cons.)
12. Abatement procedures (check all that apply):
V a. Glove Bag 7 b. Encapsulation r" c. Enclosure F d. Disposal Only j'- c.
P f. Full Containment F- g. Other - Please Specify:
13, Job is being conducted: F a. Indoors r- b. Outdoors
14 a, Total amount of each type of asbestos Containing materials (ACT[) to be
encapsulated:
1. Linear Feet (Lin. Ft )
b. Boner; Broaching, Duct,
Tank Surface Coatings 1, Lin. Ft z. Sq. Ft.
d. Pipe lasulaurna
'f. Spray -On Fireproofing
h. Cloths, Woven. Fabrics
J, insulating Cement
1. Lm. Ft. 2. Sq. Ft.
1. Lm. Ft, 2. Sq. FL
1. Lin. Ft. ' 2. Sq. Ft.
1. Lin, Ft 2. Sq. Ft.
15. Describe the decontamination systems) to be used:
3 CHAMBER WASH BUCKET
260
2. Scpare Feet (Sq. F t%)
c. Tramite Pipa
e. Transite Shingles
g. Transite Panels
i. Other - Please Specify:
FT, MASTIC
enclosed, or
1. Lin. Ft.
16. Describe the comainerizanon/disposal methods to comply with 310 CMF. 7.15 and I 6 MILL DOUBLE BAG
17, For Emergency Asbestos Operatic n.% the MassDEP and DLS officials who
a. Name of MassDEP Official It. Title of MassDEP Official
r.. Date of Authorization (M MIDDNYYY) _ d, Wawarft
e. Name of DLS OfficialM.� f. Title of
Sq, Ft.
260
Ft. 2. Sq. Ft.
3 CMR 6.14(2)
the emergency:
9. Date of Nuthorization (MMIDDNYYv)
jl
16. Do prevailing wage rates as per M.G.L. e. 149, § 26, 27 or 27A F apply to this ro- a• Yes 1M b. No
project?
xevlsea: I U iX21) Li II Page 2 of 4
6"d 99£££^0£809 oe_L oaey u1d6Z:1 OZOZ 9Z unl'
Massachusetts Department of Environmental Protection ----
IO $29724BWP AQ 04 (ANF -001) ^�
A�bi sro5njeDt#
Asbestos Notification Form J roject Revision
:T roject Cancellation
B. Facility Description
1. Current or prior use of facility:
Plots: 7omporary
slorage of Asbestos
containing waste
material is only
a!lewec attire place
of businsss of n DLS
Ilconsed Asbestos
contractor or a transfer
satlon tha: is
pormltted by
IdassDEP and
operated in
compliance with Solid
Wast. Rogalagons
310 CMR 19.D00
HOSPITAL
2. Is the facility owner -occupied residential with 4 units or less? IF a. Yes iW b. No
3 NORTHAMPTON VAMC J _ 421 N MAIN ST ^,
a. Facility Owner Name b. Address
NORTiA IPTON MA 01053 4138444040
c. Cityfrown d. State e. Zip Code f. Telephone
A NA NA
a. Name of Facility Owner's On -Site Manager b. Address
NA MA 00000
a arfirown — a. sista e.Zip code
S AEROTEC 163 RICE AVE
a. Name of General Contractor b. Address
NOR-1H80RQli
c- Cilyfrowr
ACE
g. fontradt<
656200
6. what is the size of this facility?
0000000D00
MA 01015 9787553534
d. state e. Zip Cade LTolophone�
5512021
1800 2
a. square Feet — b. # of Floors
C. Asbestos Transportation & Disposal
1. Transporter of asbestos -containing waste malarial from site of generation:
i a Directly to Landfill or r7 b. To Temporary Storage Locatioid'Fransfar
AERO TEC ENVIRONMEr.'TAL
c. Name of Transporter
NORTHBOROUGH VA
e. Cityrrown f. State
163 RICE AVE
d. Address
01532 9783759534
g.Zip Code h. Telephone
2. If a temporary storage location/transfer station is used, list name of transporter of ash estos containing
waste material from temporary storage location/transfer station to final disposal site:
RT. 173 PICKCRING ST
a. Name of Transporter b. Address
PORTLAND Cr 06480 8604211324
c. City/Town d. Stale e. "Lip Code f. Telephone
13
Page 3 014
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Massachusetts )Department of Environmental Protection �— --
BWP AQ � � As stas Q4 (ANF -001) Aa
s testes
Project #
Asbestos Notification Forth r xoject Revision
�— xoject Cancellation
C. .Asbestos Transportation & Disposal: (cont.)
3. Name and address of temporary storage location/transfer station for the asbestos con aining waste
material:
NA NA
a. Temporary Storage Location Name b. Address _
NA MA 00000 0000000000
0. Cityfrown _ d. State e. lip Code f. Telephone— --------- -- -
4. Name and location of Gaal disposal sits (asbestos landfill):
MINERVAFNMRP )ICF MINERVAINV
a. Final Disposal Site Name b, final Disposal Site Owner Name
90DO MINERVA RD
c. Address
WAYNESPERG OH 44636
d. CltyrTown z. State I. Trp Cade
Note: Contractor must
sign this form for DL5
notification purposes D.
Certification
"I certify that I have personally
examined the foregoing and am
familiar with the information
contained in this document and
all attachments and that, based
on my inquiry of those
Individuals immediately
responsible for obtaining the
information, I believe that the
information is true, accurate, and
complete. I am aware that there
are significant penalties for
submitting false information,
Including possible fines and
imprisonment. The undersigned
hereby states that I have read the
Commonwealth of
Massachusetts regulations
governing asbestos abatement
(453 CMR 6.00 promulgated by
the Department of Labor
Standards and 310 CMR 7.15
promulgated by the Department
of Environmental Protection),
and that I am aware that this
permit application or notification
shall not be deemed valid
unless payment or the
applicable fee is made."
J
cod gg£££6£809
GREGHARD'ING
3308663436
g. tetapnone
CkA N FR
6/25/2020
3. Position?tie
9783759534
4. Date (M
AERO TEC
5. Telephone
163 RICE AVE
S. Repress
NORTHBC
7, Address
MA
F city/Tov
01532
9, state
10. Zip Cc
11 Page 4 of 4
091OJOV wdl£I;OZOZ4Zunr