NYC 9/11 Public Portal Document
I24 4AssAu S -r e T
ASBESTOS INSPECTION REPORT (continued)
6. Asbestos Hauler IESI,NY NYS DEC Permit # NJ-462 Tel.# (718) 522-2263
Disposal Site(s) BlueRidge Landfill PO Box 399 Scotsdale, Pa 17254
27. This asbestos abatement is part of a (Item a through e requires filing of this forth carePI NYC Department of Buildings)
a) 0 Demolition b) 0 Baler Replacement c) 0 Sprinkler Replacement Cl) 0 Renovation/Alteration
e) 0 Fireproofing Replacement f) El Other (Describe) —_
28. TYPE OF ABATEMENT (Check all appropriate boxes)
0 Removal ❑ Enclosure ❑ Encapsulation 0 Repair Cleanup
29. ABATEMENT PROCEDURE (Check all appropriate boxes)
❑ Full Containment 0 Glovebag ❑ Tent ❑ DEP Variance Application
30. LOCATIONS OF ABATEMENT Root= MATI"R-tAci- : Re'ot:' Mlei?Aap.a..iE (miz-~
DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING
Floor(s) OF FLOOR CONTAINING ACM PERFORMED
SQUARE LINEAR to g running cable. installing fire spnnkiers.
(e g enbre. east wing, room a leg Pipe lagging. ceiling. plenum
toiler room. Iobb . etc) ducts. storage tanks decking. etc. FEET FEET removing and replaong boilers. etc)
f oOF ' ROOF SUef, PAe nA< i
iRoo F I ROOF Su2F-ACS l 25
5t~('gACiC' r~~~ _
ROG~F 2 l oc*: St3~P~~ 42S i l
6aexsuf~ 6 A0 trr_s 1000
lojesc FAceac
Fttz c i ISO
'F`hCaOC ' i t.::U1NCx (OcaTSta) I20 — •----•----
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.
Print Name of Air Monitor ?nnt Name of Asbesps Contractor Print Name of Applicant (If other than Qwner)
Signature/ Signature
Z
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.
f t
DET? 113 1(32
Print Name of Oviner turo Date
A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.
LAny modification of information provided on this form must be reported immediately in wilting directly to the NYC DEP ACP.
The requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened
through the perfonnance of work in incremental or piecemeal fashion. AC??
NYC-WTC 000098738
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