Asbestos project notification form, 114 Liberty Street, 2003

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler Tri State Transfer Assoc. NYS DEC Permit # 1A375 Tel.# (718) 617-0661

Disposal She(s) BFI imperial Landfill, 11 Boggs Road, PO Box 47, Imperial, PA 15126 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) ❑ Sprinkler Replacement d) 0 Renovation/Alteration e) ❑ Fireproofing Replacement f) El Other (Describe) ACM Removal Only _`

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) El Full Containment ❑ Glovebag ® Tent 0 DEP Variance Application

.An LOCATIONS flF ARATFMFNT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, eat wing. room #, (e.g. Pipe tagging, ceiling, plenum SQUARE LINEAR (e.g. nursing cable, instating Are aprinkle+s, boiler mom, lobby. ate) ducts, stomee tanks, etc FEET FEET romovino and ropladno boilers eta) Bsmt Boiler Room Pipe Lagging 80 ACM Rem, Tent/Glovebag Bsmt OII Tank Room Ceiling Block 144 ACM Rem/Tent Containment Bsmt Water Meter Room Pipe Lagging 16 ACM Rem, Tent/Glovebag Bsmt Water Heater/Storage Pipe Lagging 6 ACM Rem, Tent/Glovebag 1st Pizza Restaurant Spray-On/Plaster 824 ACM Rem/Full Cont. w/variance 1st Miam Restaurant Pipe Lagging 64 ACM Rem/Tent Cont. w/varlance 2nd Bathroom Pipe Lagging 10 ACM Rem, Tent/Glovebag 3rd Apt./Hallway Pipe Lagging 128 ACM Rem, Tent/Glovebag 9th West Hall Pipe Lagging 24 ACM Rem, Tent/Glovebag

31. I 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.

Hilimann Environmental Co. Inc. ETS C racting, C. ETS C ttracting a of Air r r t me of esios contractor Print/# other than Owner)

f re Signature Signature

7 Z$ 7/29/03 7129/03 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 Involy asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein. Liberty, LLC ~sil Punt Name of Owner E' S#5 .. G_ signature _ i 2'S 00 ilate 3 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. requirements of the Asbestos Control Program Rules may not be G:7 through the performance of work In Incremental or pieces //o3qM2 1

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