Asbestos project notification cover sheet

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 1 26. Asbestos Hauler ATC NYS DEC Permit# 1A-371 Tel.# 631 ) 924-5050 DisposalSite(s) Southern Alleghenies Disposal Svcs. Road 3 Box 310 Valleyview Dr. 27. This asbestos abatement is part of a (Item a Hoilsopple PA 15933 through a requires filing of this form with NYC a) ❑ Demolition Department of Buildings) b) ❑ Boiler Replacement c) 0 Sprinkler Replacement d) 0 Renovation/Alteration e) 0 Fireproofing Replacement f) Other (Describe) Asbestos Containing Dust 28. TYPE OF ABATEMENT (Check all appropriate boxes) 0 Removal 0 Enclosure 0 Encapsulation 0 Repair 13 Cleanup 29. ABATEMENT PROCEDURE (Check all appropriate boxes) Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application 30. LOCATIONS OF ABATEMENT nrrr-t, I CL) JUKtAGtb AMOUNT OF ACII ¶M4. 1gts ta i . Floor(s) I OF FLOOR DESCRIPTION OF WORK ING (e.g. entire, east wing, room #, CONTAINING ACM (e.g. Pipe lagging, ceiling, plenum SQUARE LINEAR PERFORMED. iucts, storage tanks, dedcin , etc.) (e.g. running cable, installing fire sprinklers, FEET FEET ,art,un aria replacing oouers,, Roof Entire All in ludln g 2,500 Cleaning of ACM ntire All 'nc uding 1,800 I Cleaning of ACM

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

l3N \ cat'&, - c (1~ t L ~Cr c irt , ~1h-e av c ( Print Name of 'r Monitor 'y k Print Name of Asbestos Contractor . Print Name of Applicant ~(If other than Owner)

j Signature 1 / / ( c. Signature Signature

1 c~~a-t ly t 32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the asbestos abatement activities in accordance with the the performance of Asbestos Control Program Rules. I have contracted the third party air monitor who is completely independent of all parties filin of this not ication for involved in the asbestos p oject. I hereby declare that I have authorized ork specified herein. the

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 through the performance of work in incremental or piecemeal avoided or lessened fashion. RCPT 212001

NYC-WTC 000100523