Asbestos project notification form, NYC DEP

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler 1ES I , 1139 NYS DEC Permit # WJ - 46 2 — Tel.# C.1 $8) 522- 22>E..3

DisposalSite(s) BWEPAD6E LAWDF'iLL P0 Box 399) SCCrMJ>AL R. IT254

27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Build(ngs) o ' a',. a) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement f) 0 Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application / / Øj P0Z ~P v 30. LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room #, (e.g. Pipe lagging, ceiling, plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers, boiler room, lobby, etc) ducts, storage tanks, decking, etc.) FEET FEET removing and replacing boilers, etc.)

ROOF ROOF Sut .FACE 2940

u SYJ~Lo N15 $t?1Ku is 1000

t=Ae.{►oe I oaztt 1'IkCAD 1625 N fteE SfGU ___ S~vTN Fn.cs& cx Su¢rø.ces 26 5 •e N NFr)t.. Si.to'rft s 2625

i~ 00exs 4 ~.i i - - 4000

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.

WAeREa 4 "PaNZ.Ge _ INEERs T. (P..A1pyBMJ 4 Soe4 CausaoL la Print Name of Air Monitor Print Nam f Asbestos tractor Print Name of Applicant (If other than Owner)

Signatu Signature Signature

to1.3 ( 6 '2- to 1o3la2 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. _ ~Y Aaln3 Date 102 — o• Print Name of Owner Signature

A A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.

Aci .modification 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 throw h the erformance of work in incremental orpiecemeal fashion. ACP7 2naot

NYC-WTC 000094345