Asbestos inspection report form, 2002

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler ATC NYS DEC Permit # _1A371 TEL.# (516) 924-5050 Hollsopple, PA Disposal Site(s)S. Alleghinies landfill, RD3 P.O. Box 310,

27. This asbestos abatement is part of a (Item a through a requires filing of this form with NYC Department of Buildings) a) 0 Demolition b) 0 Boiler Replacement c) ❑ Sprinkler Replacement d) 0 Renovation/Alteration

e) 0 Fireproofing Replacement f) El Other (Describe) Emergency Asbestos clean up

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) '77,(Goa /

❑ Full Containment 0 Glovebag ❑ Tent El DEP Variance Application en I nnATrnuc

I ne efATeIFUT

JV I_vv^ 'DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SQUARE LINEAR (e. running cable, installing fire sprinklers. (e.g. entire, east wing. room f►, (e. Pipe lagging, 9, plenum 9gan ceiling, FEET 9storage tanks. decking,etc. ducts, FEET removing and aci boilers, etc.) boiler room, lobby. etc

Bsmt Entire all affected surfaces 4,500, 0 ACM clean up only

1st lallway & APT A,B,C,D all affected surfaces 4,750 0 ACM clean up only

2nd Hallway & APT A,B,C all affected surfaces 4,500 0 ACM clean up only

3rd lallway & APT A,B,C all affected surfaces 4,500 0 ACM clean up only

4th -lallway & APT A,B,C all affected surfaces 4,500 0 ACM clean up only

5th allway & APT A,B,C all affected surfaces 4,500 0 ACM clean up only

6th allway & APT A,B,C all affected surfaces 4,500 0 ACM clean up only

7th Hallway & APT A,B,C all affected surfaces 4,500 0 ACM clean up only

8th allway & APT A,B,C all affected surfaces 4,500 0 ACM clean up only

9th Flallwat & APT A,B,C all affected surfaces 4,500 0 ACM clean up only

Federal, 31. 1 hereby declare that the information provided herein is true and complete to the best of my knowledge. I am familiar with State and NYC laws and regulations applicable to asbestos related work.

Central Environmental Inc. Black Rock Construction Co. Tony Brown Pun ame of Air itor Print Name of Asbestos tractor Print Name of Applicant than Owner)

nature Signature Signature

12/10/01 12/10/01 12/10/01 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 'n the asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein. 12/10/01 65 Nassau Owners Corp. Print Name of Owner Signature Date

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

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 ACP7 throuah the Derformance of work in incremental or piecemeal fashion. 212001

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