NYC 9/11 Public Portal Document
ASBESTOS INSPECTION REPORT (continued)
26. Asbestos Haule
Disposal Site(s)
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) ❑ Renovation/Alteration
e) 0 Fireproofing Replacement f) 0 Other (Describe)
28. TYPE OF ABATEMENT (Check all appropriate boxes)
❑ Removal ❑ Enclosure ❑ Encapsulation 0 Repair ❑ Clean up
29. ABATEMENT PROCEDURE (Check all appropriate boxes)
❑ Full Containment 0 Glovebag 0 Tent ❑ 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 N. (e.g. Pipe tagging. cuing. plenum SQUARE UNEAR (e.g. running cable, installing rue sprinklers.
baler room. , etc ducts. tanks. . etc. FEET' FEET and boilers. etc
1
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.
suers
Print N
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' Name/ as Contractor
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Print Na of App ant (N other than owner)
Signature lure signature
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Date Date Date
32. 1 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 invoheed in the asbestos project. I hereby declare that I have authorized the
fill of this rtotificati r the specified herein. t •'
A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLEAF°THE WORK SITE.
i
1 aL —
LAny 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. 1 AM
NYC-WTC 000100491
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