11 JOHN STREET

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler t€St, NY NYS DEC Permit # WJ - 462 Tel.# (its) 522-2263

Disposal Site(s) Bute RaDGE L "OFti►.L p0 BOX 399 Sco1SDA+.E PA IT25 4

27. This asbestos abatement is part of a (Item a through e 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) ❑ Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application

•ln I nflATIAAIC AG ARATPIA MT 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 p, (e.g. Pipe lagging, ceiling, plenum FEET FEET removing and replacing boilers, etc.) boiler room, lobby. etc) ducts, storage tanks, decking, etc.)

t=ACADE JOHN Si. FACADE FACADE SUR-FACES 0300 3RD FLOCC ID ST9EET

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.

WIC f PANZER es .I) ..s B. V-UeZBAN 4 SON CONTROL Print Name of Air Monitor P ' t Name of Asbestos C Print Name of Applicant (If other than Owner)

2_ - Signature? " j " Signature Signature

OT-12-02. OZ-12-02 Date Date Date

32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the performance of the asbestos abatement activities in accordance with the Asbestos Control Program Rules. I have contracted the third party air 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. pC OT-12-O2 Signature Date Print Name of Owner

A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. directly to the NYC DEP ACP. Any modification of information provided on this form must be reported immediately in writing requirements of the Asbestos Control Program Rules may not be lawfully avoided or iessenea through the performance of work In incremental or piecemeal fashion. ACP7 anoot

NYC-WTC 000094130