Asbestos project notification form, 30 West Broadway, Aug 2002

NYC 9/11 Public Portal Document ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler LO NYS DEC Permit Tel. Disposal sites) e21~ l~ 'e5 n-~ (='~ 1- 27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) ~'. a) O Demolition b) O Boiler Replacement c) O Sprinkler A Replacement P d) O Renova6oNAfteratiori-' • e) O Fireproofing Replacement f) O Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal O Enclosure ❑ Encapsulation O Repair Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment O Glovebag O Tent O DEP Variance Application 30. LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM Floor(s) OF FLOOR DESCRIPTION OF WORK BEING (e.g. entire, east wing, room Ir, CONTAINING ACM PERFORMED (e.g. Pipe lagging. ceiling plenum SQUARE UNEAR (e.g. running cable, installing fire sprinklers, boiler room. lobby, etc) ducts, storage tanks. decking, eta) FEET ' FEET removing and regladng boilers. etc

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TZI W -e _______________

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

Pnnt N r Aar Prim Name fAsbestos Contractor Prim of App ant (If other than Owner) £ _______

Sgnature nature Signature

Date Oate 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 r . monitor who is completely independent of all parties involved Control Program Rules. I have contracted the third party air in.the asbestos project. I hereby declare that I have authorized the : .. filing of•this notification for the work specified herei _____________________ Print '-_-_...L._ ____________

;. 1f .~.Name of Signature Date tt STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE

the Asbestos Control Program Rules may not or lessened h the performance of work in incremental or o ACPI pool

NYC-WTC 000109849