Asbestos project notification form, Corona NY, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler ATC NYS DEC Permit # 1A•- 3 71 Tel.# J 6 31) 9 2 4 — 5 0 5 n

Disposal Sites) Southern Alleghenies Di posal Road 3 Box 31 fl Val 1 e Svc'a iew Hollsopple PA 15935 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) ❑ Bober Replacement c) ❑ Sprinkler Replacement d) ❑ Renovatio iAtteration Asbestos Containing Dust e) ❑Fireproofing Replacement t)o Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) Ig Fun Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application i ij` j7 $ 0' %n I APAri# IIQ nC £QATCUCIIT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (ap. S *L eat wkq, mom R. (..a Piv Upping clam. piersan (e.g. Ard*Q oobts. inshttrw tbs sgtUJ rs. boxeoom rr duds, e FE ar

Roof Entire Sue ring f R of 3,0 0 Cleaning of ACM

Federal. 31. I hereby declare that the information provided herein is true and complete to the best of my knowledge. I am familiar with State and NYC laws and reoulations applicable to asbestos related work.

J.C. BrodeZ•ick & 1 2 Banc1 Interior 192 Branch Interior Associat s rnt Nsms er ttaet Owned Print Nims or Air Mont Prim estoe Contractor ams d _______

2n cJ /L1 gnature Signature Signature

/oi rriz4of Date Date Dc

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 authorized the monitor who is completely independent of all parties involved in the asbestos project. I hereby declare that I have filing of this notification for the work specified herein. Zu/M(S (Ai 5(3 Signature LL/21L2±__ Date Print Nameof Owner

A STAMPEDCOPYOFTHISFORMINCLUDING AMENDMENTSMUSTBEAVAILABLEATTHEWORKSITE. Any modification of information provided on this form must be reported immediately in writing directly to the NYCDEP 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. r1 2KI00

NYC-WTC 000109635