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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description
100113345 •�
Decal Number
1. a. is this facility fee exempt - city,town, district, municipal housing authority, owner -occupied
residence of four units or less? 1✓j Yes Cal No r __
b• Provide blanket decal number if applicable: Ila -••• -" _----
Blanket Decal Number
2. Facility Location:
;788 SOUTH MAIN STREET
_ - - -
a. Name'of ....... ...-,...._t ..."•.........•._.
iMansffeld _ MA
o, aty/Town
F788 SOUTH MAIN STREET-______�
b, et Address .,w.,....,...
CO2048 1 (508) 833.2603
e. zip Code f• Telephone Number
3. Worksite Location:
1788 SOUTH MAIN STREET L J 121 BSMT KITC
f. All sections of this �a. BuildI09 None Bulldin Location b. Bulldln # c. Win d. Floor e. Room
form must be 9 9 9 0
completed In order
to comply with 4.
D5P notification
requirements of 010
CMR 7,15 5.
end the DhAslon
of Occupational
Safety (DOS)
notification
requirementt of 453
CMR S.12
8.
7,
0.
9.
Is the facility occupied? (1 Yes [K No
Asbestos Contractor:
(ECONOMIC ENVIRO TECHS
e. Neme
j0142(I
FITCHBURG l
_
IAC0004151. 9
jB--
ILL MCCAMBRIDGE
h__ecllty-_on act__ersan..
... ...... .... _...._....___
!HENRY MOSES
..........................�
a, Name.of OnSlte SugdNispr�oraman,,...-�__
JOHN BACHAND
.NORTHEAST ENVIRONMENTAL LABS
C. work hours Mon -Fri.
10. a. What type of project is this?
✓� Demolition 1:1 Renovation
Repair Other, please specify:
11. a, Check abatement procedures:
_} Glove bag hM� Encapsulation
j Enclosure 11: Disposal only
1 Cleanup r J Other, specify:
;✓� Full containment
38 INTERVALS ROAD "�• ,�_, _
b. Addraas
9784233909
e. Telephone Number"
g. Contract type: Z Written rt 1 Verbal
b, Describe
b. Describe ......•......
12. Is the job being conducted: jJ] Indoors? Z Outdoors?
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Asbestos Notification Form - Page 1 of 3
09/17/2010 14:07 6039290341 JFORSES PAGE 03/04
0 Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cunt.)
13345
'& 00came 11Numrier
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
enceosulated__.,,_.__._--
730 _.._� j461 ._.._.—_..----•....__�
a.l'atel`plpeeorrt-ucis�llnesiTi -FTfeTo�iers squarefIT
c. Boiler, breaching, duct, lank
I I
surface coatings
in. ft.
e. Corrugated or layered paper
pipe insulation
Lin, ft,
g. spray -oft fireproofing
Lin, ft.
�•
I. Cloths, woven fabrics
Lin. ft.
r—
k.Thermal, solid core pipe
(,
insulationn,'f(.
14. Describe the decontamination system(a) to be used:
i3 CHAMBER
d. Insulating cement
! I
f. Trowel/Sprayer coatings
i�..,_-...
Lin. fl.
h, Trsnsfte board, wall board
�L n—;=- -
J. Other, please specify:
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2)(9)i.-- ...................
.
.__...__.._..............__._.._._..—....__........,.,._ _._....,...,.
I(2) 6-MIL BAGS WETTED
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? n Yes [] No
B. Facility Description
1. Current or prior use of facility: 1DMMERCIAI-
2. Is the facility owner -occupied residential with 4 units or less? Z Yes O No
3,
4.
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Asbestos Notification Form • Pa e 2 f 3 m_
09/17/2010 14:07
6039290341
JFORBES
PAGE 04/04
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulafions 310
CMR 10,000
Commonwealth of Massachusetts
Asbestos Notification Form) ANF-001
,100113345
Decal Number
B. Facility Description (cont.)
ECONOMIC ENVIRO TECHS INC. 30'INTERVALE ROAD
a. Name of General ConUactor Address _._Nam,,,.,...,,...,.,,._.__...._...........................--
pITCHBURG �014z0 (970) 340.1119.
__ d_Zi -Code ___ e, Telephor�g Number„(area codMi—=
IZURICH-AMERICAN INSURANCE GROUP _ [6=ZZ—UU84108P10209 I Werker�a Comp Ineurer g. Policy Number ate fmm/ddNvwl
6. What is the size of this facility? la, Square Feet - .... 6 Riimber of Ooori- j
C. Asbestos Transportation and Disposal
1, Transporter of asbestos -containing material from site to temporary storage site (if necessary):
SERVICE TRANSPORT GROUP 59 PYLE5 I ANE
a. Name f Transporterb.Address
INEW CASTLE, DE - .. .1 19720 �(977 999.9559
NEWCASTLE, LE,
e. ChylTown d. zip Code e, Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
3.
4.
11225 STATE ROUTE 45
a Fipal,Disgugai,Site„„Address,,,_______. _ .,._.
OH i44432
e. Slate f. Zip Coda
D. Certification
The undersigned hereby states, under the
penalties of perjury, that helshe has read the
Commonwealth of Massachusetts regulations
for the Removal, 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,
INTERVALE ROAD
I. zip cone
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