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

Disposal SRe(s)S. Alleghinies landfill, RD3 P.O. Box 310, Hollsopple. PA

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) ❑ Boiler Replacement c) 0 Sprinkler Replacement d) 0 Renovation/Alteration a) 0 Fireproofing Replacement I) El Other (Describe) Emergency Asbestos clean up

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ~0 / ((6I ❑ Full Containment 0 Glovebag 0 Tent 0 DEP Variance Application

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 etc) ducts tanks, decking, elk.) FEET FEET removing and mpladng boxers etc.)

10th lallway & APT A,B,C all affected surfaces 4,500 0 ACM clean up only

31. 1 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.

Central Environmental Inc. Black Rock Construction Co. Tony Brown Print Name of Air Monitor Print Name of Asbesas Contractor Print Name of Appli t (If other than Owner)

/Signahxe sip ture 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 Asbe Control Program Rules. I have contracted the third party air monitor who is completely independent of all parties in ed the asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein. 65 Nassau Owners Corp. 12/10/01 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 ACP7 0 through the performance of work in Incremental or piecemeal fashion. 2!2001

NYC-WTC 000099923