Asbestos project notification form, 200 West Thames

NYC 9/11 Public Portal Document

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ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler JBT NYS DEC Permit # IA_375 ___ Tel.# (718) 617_0771_____ N

Scottsdale, PA Disposal Site(s) Greenridge Reclamation_

27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) ❑ Demolition b) 0 Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration ❑✓ Emergency Asbestos Clean-up (E-175_01) e) 0 Fireproofing Replacement f) Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 Glovebag 0 Tent ❑ DEP Variance Application

SU. l_t7CAT10NS OF ABATEhrr-us r DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING OF FLOOR CONTAINING ACM PERFORMED Floor(s) SQUARE LINEAR (e.g. running cable, installing fire sprinklers, (e.g. entire, east wing, room JF, (e.g. Pipe lagging. ceiling, plenum n , etc.) FEET FEET removing and replacing boilers, etc.) boiler room, lobby, etc) ducts, ore storage a tanks,

Master bed room & bath floor 300 Emergency asbestos dust clean-u 8

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

A is s, I c. PAL Environt11 tal Safety Corp. .. PAL vir nmental Safety Corp. ---------- -------------- ------ -- — ------------------------ other than Owner) ------ Print Name Asbestos Contract o ppl( t (If \ riot N e of 'Monitor

----------- ---- -~ ------- - ------ - -----.---------------------- .7 - Signature ~. Signature Signature

_/ 2"---------------- Date ------- I ------- --- -- ----------------------- Date Date

responsible for the performance of 32. I understand that as the owner of a building where asbestos abatement activity occurs. I am activities in acordance with the Asbestos Control Program Rules. I have contracted the third party air the asbestos abatement monitor who is completely independent ofe1Lai ies involved in the asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified her Dianna Jacobowitz -------------------------------------- ~~- ~""`` ~ = // Date Print Name of Owner Signature

WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE

Any modification of information provided on this form must be reported immediately in writing directly to the NYC DEP ACP. I requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened through the- Qerformance of work -- in incremental or piecemeal fashion. ACPI ?ZOnt

NYC-WTC 000110085