Asbestos project notification and inspection report form

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION (continued) REPORT 26. Asbestos Hauler Lc NYS DEC errnitff 7 Z'~~6r,o Disposal Site(s)

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) ❑ Boiler Replacement e) ❑ Sprinkler Replacement d) ❑ RenovatioNAfteration e) ❑ Fireproofing Replacement fj ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair ❑ Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application 30. LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM (a .g entire. east wing. room /, (e.g. Pipe tagging. ceanp, plenum SQUARE LINEAR PERFORMED Ogler tOom, (e.g running Cable. instan' rae etC ek+Cye, tanks. OtC. FEET • FEET removi and re laci g boiWit etc ~

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31. I hereby declare that the information provided herein is true and State and NYC laws and regulations applicable to asbestos related complete to the best of my knowledge. I am familiar with Federal, work. _ P.vn N v '(,-t itor / t:rxJ Name As — stos Contractor 4257 ?v Pnnt Nan of App a (, Cat (H other than Owner)

Signature gnature Signature OC- 03 -0~ _ ___ Date Date Date 32. 1understand 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 all parties involved in the asbestos project. I hereby ling f this notificationj the work declare that I have authorized the cified herein. 11011151*-' Pram Name otO. er Sipn.Ose Oat A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE _LAny modification of information provided on this form must be reported immediately in writing directly to the NYC DEP ACP. Control Program Rules may not or Ate araoo,

NYC-WTC 000110382