Asbestos project notification form, February 2003

NYC 9/11 Public Portal Document

FEB.26. 2003 6:02PM ETS INC. NO. 543 P. 3 ASBESTOS INSPECTION REPORT (continued) 28. Asbestos Hauler Tri-State Transfer NYS DEC Permit# 1A-375 Tel.# 18) 617-0661

Disposal Site(s) SFi Imperial Landfill, 11 Boggs Road, PO Box 47, Imperial, PA 15126 27. This asbestos abatement Is part of a (stern a through a requires thing of this form with NYC Department of Buildings) a) © Demolition b) Q Boiler Replacement c) ® Sprinkler Repiaoement d) 13 Renovation/Alteration e) ❑ Fireproofing Replacement 1) 21 Other (0esaibe) ACM Removal

28. TYPE OF ABATEMENT (Check all appropriate boxes) ® Removal ❑ Enclosure ® Encapsulation ❑ Repair 21 clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) 0 Funpntaln G Tent DEP V on {as sr -DE9, :c=LB cn tract proace 14 30. LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK SEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (&g• entIre, east wing, room #, (e Pip. ragging, ceiling. plenum UNEAR (e g. mooting aeb9, i ng fire apr*tera.

1st Entire All Surfaces 6,000 ACM/Debris Clean -Up 2nd Entire All Surfaces 6,000 (es per WTC-LBtI IC-DEP 3rd Entire All Surfaces 6,000 Contract Procedures) 4th Entire All Surfaces 6,000 5th Entire AD Surfaces 6,000 8th Entire All Surfaces 6,000 7th Entire All Surfaces 6,000 8th Entire All Surfaces 6.000 9th Entire All Surfaces 6.000 10th Entire All Surfaces 6.000 ç~ qth En re ur aces e Surfaces 31. i hereby declare that the information provided herein Is true and com of my knowledge. I am familiar with Federal, State and NYC raves and regulations applicable to asbestos related work.

JLC Environmental Cons., Inc. ETS Contracting, Inc. ETS Contracting, inc. Print Nef of Air Mwftt Pont Ns ne of Asbestos Conbaator Print Name of ApOkant (trotter than Owner)

oratnre sisnrwre signature

Data 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 aH parties involved in the asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein.

Print Nam* of Owner Signature Daze

A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. Any tion of' rotation provided on this form must be reported immediately to the DEP ACP

NYC-WTC 000102603