NYC 9/11 Public Portal Document
80 NASSAI, 5-r ee;i5 —
ASBESTOS INSPECTION REPORT (continued)
26. Asbestos Hauler IESI,NY NYS DEC Permit # NJ-462 Tel # (718) 522-2263
Disposal St(s) BlueRidge Landfill P0 Box 399 Scotsdale, Pa 17254
27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings)
a) 0 Demolition b) 0 Boiler Replacement c) 0 Sprinkler Replacement d) 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 Clean up
29. ABATEMENT PROCEDURE (Check all appropriate boxes) ~~ /~ /3~ Y
❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application k a0
30. LOCATIONS OF ABATEMENT P.COF A-rE2 to '.- : e00 F M0A PBfLAwtE (r -)
DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING
Floor(s) OF FLOOR CONTAINING ACM PERFORMED
(e.g entire. east wing, room p, (e g Pipe lagging. ceiling, plenum SQUARE LINEAR (e g running cable, installing fire sprinklers.
boiler room, lobby, etc) ducts. storage tanks. deckin , etc.) FEET FEET removing and replacing
replaong boilers, etc.)
QC'0F rF Suac ce 7244
it PA(z,o'pe'r 464
tt 2.040
it A/0. L'N t T5 200
o s,, 1000
E?tS T t .AE (D.SCj
tl WOST RNa^VE 5220
q Sr Lrrl.i _-fac.A D iE 5CzI
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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.
CuAga.eti pf~>,za_►a ,tN as_ C3f_.IJ,. AM l N k.t RZl 5 So►! Ccp
Pnnt Name of it AAorntor Print Name of Asbestos Contractor Print Name of Applicant (If other than Owner)
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Signature Signature Signature
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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.
arch O6 28 102...
Print Name of Owner Signature Date
A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE
I Any 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
through the performance of work in incremental or piecemeal fashion. ACP7
212001
NYC-WTC 000099461
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