Asbestos Project Notification Form, DEP Box 34

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) zu. Asbestos Hauler A'1'L NYS DEC Permit # 1A- 3 71 Tel.# (6 31) 9 2 4 - 5 0 5 0 DisposalSite(s) Southern Alleghenies Disposal Svcs. Road 3 Box 310 Valleyview Dr. 27. This asbestos abatement is part of a (Item a through a requires Hoilso PA 15933 filing of this form with NYC Department of Buildings) a) ❑ Demolition b) ❑ Boiler Replacement c) 0 Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement t) 0Other(Describe) Asbestos Containing Dust 28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) Full Containment ❑ Glovebag ❑ Tent 0 DEP Variance Application 30. LOCATIONS OF ABATEMENT tAA..I1 T a Floor(s) OF FLOOR DESCRIPTION OF WORK kING (e.g. entire, east wing, room p, CONTAINING ACM PERFORMED. . Pipe lagging, ceiling, plenum SQUARE UNEAR boiler room, lobby. etc) FEET FEET (e.g. running cable, installing fire sprinklers, removing and replacu,g boilers, eta Roof Entire l,inpluding 2,500 Cleaning of ACM Entire All_4nc~.uding 1 1.80 Cleaning of ACM

31. 1 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 relaters work familiar with Federal,

(iN \k, Print Name of -r Monitor Print Name of Asbestos Contractor Print Name of Applicant (if other than Owner)

Signature Signature Signature

1 l~ l2ktD~ Date 16la (AD1 , DIOL(ly is Date Date 32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the the asbestos abatement activities in accordance with the performance of Asbestos Control Program Rules. I have contracted the third party monitor who is completely independent of all parties involved air in the asbestos p oject. I hereby declare that I have authorized filin of this not ication for ork specified herein. the

Pnnt Name of Owner Signature Date A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. LIAny 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. ACP7 ?12001

NYC-WTC 000100528