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 Tei.# (718) 617-0861

Disposal SIte(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) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement f) 0 Other (Describe) ACM Removal Only

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) 0 Full Containment ❑ Glovebag 0 Tent 0 DEP Variance Application .An 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 waghg, c elling, plenum SQUARE LINEAR (e.g. rinrJng cable, Installing fire sprinkles, boiler mom, lobby, stc) ducts, tanks, decd etc) FEET FEET removing and replacing boilers, etc.) Bsmt Boiler Room Pipe Lagging 80 ACM Rem, Tent/Glovebag Bsmt Oil 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/variance 2nd Bathroom Pipe Lagging 10 ACM Rem, Tent/Glovebag 3rd Apt./Hallway Pipe Lagging 128 ACM Rem, Tent/Glovebag 9th Nest 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.

Hillmann Environmental Co. Inc. ETS cling, c. ETS tracting rin am d Air n r t me d estas cacdracdor Print of (H other then owner)

' re taignehcra Signature

Z.$ 7/29/03 7/29/03 Data late 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 Asbestos Control Program Rules. I have contracted the third party air monitor who is completely independent of all parties invoN asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein. Liberty, LLC tli.uidl. E' St G r

J tW`e Z,g Oo3 Print Namd owner Signature ate

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 avoided or lessened through the performance of work In Incremental or piecemeal fashion. ACP?

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NYC-WTC 000102547