DEP form for non-asbestos project at 120 Liberty Street, November

NYC 9/11 Public Portal Document

11/21/2003 11'b8 FAX 718 897 4387 SAMSON MANAGEMENT f~002

FOR oerici . USG ONLY NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION 4+ o Asbestos Control Program 1. DP I 59-17 Junction Boulevard, 9ei Floor, Corona, NY 11385-5107 NYC Mlding Oap. App1I'lw 6

°NL rvPErvat7TEN NOT AN ASBESTOS PROJECT ACP 5 Fee i PORMSWILL WWr.• •v/de BE ACCEPTED When submlttIng this form at the NYC Department of Buildings. the original toms and three (3) copies with ortgInal slonature and seal are reoulred. Submittal at the h YCOEP requires one copy of the form with orginal slonattre and seal.

2. Facility Address 120 Liberty 5 treat Borough Manhattan zip 10006

AKA 125 Cedar Street 3. Block 52__ 4. Lot 21

5. Building Owner 120 Liberty Street LLC Tel. # (718) 830-0131

6. Address 120 Liberty Street State NY W__ Zip 10006

7. Contact Person Angela Ciccone -,_,— , a. Tel. # (71 8300131

9. Description of the Entire Scope of Work —

10. Est Start Date _ ❑✓ As soon as permit approved Est. Completion Dare of the Entire Scope of Work_

11, 1, Jorge Gajer ___, have conducted en asbestos Investigation on 11/12/03 In accordance with Nam of Caroasd baea033 Irnatge or oeb Sections 1-16 and 1-27 of the NYC DEP Asbestos Control Program Rules and declare that at said facility address, the a. premise to be demolishes is free of any asbestos containing material (ACM). ❑ b. premise to be demolishec contains 10 square feet or less or 25 linear feet or less of ACM. ElC. cumulative surfaces of stricture(s) affected by the work are free of ACM. ❑ d. cumulative surfaces of structure(s) affected by the work contain 10 square feet or less or 25 linear feet or less of ACM ❑ e. normally non-friable ACM shall be disturbed/removed. Specify amount square feet ❑f. ACM will not be disturbed during the scope of work_ Specify amount of ACM present square feet linear feet

All ACM specified in "b", `d", or "e" must be removed In accordance with the DEP Asbestos Rules or NYS 0OL ICR56.• 12. RESULTS OF BUILDING SURVEY AND HAZARD ASSESSMENT: FLOOR DESCRIBE SECTION ALL MATERIALS NUMBER OF ASBESTOS ro OF FLOOR ASSUMED TO CONTAIN ACM SAMPLES PRESENT ASSUMED and Ore (e'p' mere` tey'~"a' 1MR e' oeRW 'Uom p4r' aa> AND/OR SAMPLED ANALYZED YES NO ACM cellar Boiler room visible surfaces 0 ✓

13. Analytical Laboratory N/A _ of Nrvr yo 14. ELAP # N/A I S. te(s) Samples Analyzed NY& 16. I hereby dada m:l n provided herein Is true and complete. 94654 11/12/03 (718) 756-6205 Y ` N e Celre ars Nomo.' am O"Orm Telophono Nuroor - -y ✓ ~' Q / $i'AL ~r Any mod' on a DONNj ation provided on this form must be reported immediately In OF writlng dlr to the e uiramenis of the Asbeatns Control Program Rules may not be NYC . lawfullyavoid I h the performance of wow in Incremental or pleoameat fashion. CER71fED ~Fp - • J~~' ASBESTOS U►gemoperaUone.es b In5 .3.1orrcma.wenotoenrwmN NewYakG. N SBt:$TQS \ ~ INVESTIGATOR a0p5 moor

NYC-WTC 000107421