17 JOHN STREET Block: 79 Lot: 10 BIN: 1001216

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler _ ( ) c3 m j o NYS DEG Permit gam-a72-3 7 Disposal Site(s)

27. This asbestos abatement is part of a (item a through a requires filing of this form wfth NYC Department of Buildings) a) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement • d) ❑ RenovationlAlteration e) 0 Fireproofing Replacement f) ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) A El Removal ❑ Enclosure 0 Encapsulation ❑ Repair ❑ Clean up

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Giovebag ❑ Tent ❑ DEP Variance Application 30. LOCATIONS OF ABATFUFtrr DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire. east wing. roan 1. Pipe lagging. Wi g. plenirn SQUARE 1.NIEAR (e.g- runtw g cable, installing line sprinklers. boiler room, . etc (e.g- SET • FEET ducts, storage tanks, . etc. rsmngand replacing boilers. etc )

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.

Sut ( Flt-t It( ,cz23 73y T A) 1 / 2c-VC ^' Print itor Name Contractor Prins Na. of App nt (N otter than Owner) ~,p

SgnaL+re nature Sgnaturo

Date Date Date

32. 1 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(.'rs notification for the work specified herein. •

A .

Pant Name of Owner sipnatune 9) oet J A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.

[lAny inodification of information provided on this form must be reported immediately in writing directly to the NYC DEP ACP. The requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened through the performance of work in incremental or piecemeal fashion. t CP7 !2)001

NYC-WTC 000094296