11 JOHN STREET

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

28. Asbestos Hauler IESt, NV NIPS DEC Permit# NS- 462 TeL# (710) 822-2243

Disposal Sites) Bwe R4DGE LMJDFILL PO BOX 399 ScoiWAt* Pss 11254

27. This asbestos abatement is part of a (Item a through a requires filing of this form with NYC Department of Buildings) a) ❑ Demolition b) O Boiler Replacement c) ❑ Sprinkler Replacement d) O Renovation/Alteration e) O Fireproofing Replacement f) O Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation O Repair ® Clean up

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment O Glovebag O Tent O DEP Variance Application 'n t nP ATInh1Q nC AQATCIAC61T

DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SQUARE LINEAR (e.g. running cable. installing fire sprinklers, (e.g. entire, east wing, room N. (e.g. Pipe lagging, ceiling, plenum FEET FEET removing and replacing boilers, etc.) boiler room, lobby. etc) ducts, storage tanks, deciti , etc.)

FACADE JDNN Sr. FACADt= FACADE SuaFACES 6300 RD FLooe 90 STREET

31. I hereby declare that the information provided herein is true and complete to the best of my knowledge. I am familiar with Federal, State and NYC laws and regulations applicable to asbestos related work.

WcY 4 PANz a U.)ES B. fwlzzaaa.t 4 Sorg t O'T¢ol. Print Name of At Monitor Pn t Name of Asbestos C etor^ Print Name of Applicant (if other than Owner)

Signature Sgnature Signat.:•e

OT-12-02.. Ol-12- 0 2 Date Date Date

of 32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the performance party air the asbestos abatement activities in accordance with the Asbestos Control Program Rules. I have contracted the third monitor who is completely independent of all parties involved in the asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein. Ne pEp oT -12-02 Date Print Name of Owner Signature WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE the NYC DEP ACP. [ Any modification of information provided on this form must be reported immediate!y in writing directly to The requirements of the Asbestos Control Program Rules may not be lawfully avotdea or ACPT V200t

NYC-WTC 000094124