Asbestos project amendment form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION (continued) REPORT —0/ 26. AsbestosHauler ff W NYS DEC Permit Tel. 2.72^

Disposal Site(s) _0U I 1 1€

27. This asbestos abatement is part of a (Item a through a requites6fr of this form with NYC Department of Buildings) a) C] Demolition b) Q Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ RenovatiortAlteratic e) ❑ Fireproofing Replacement f) ❑ 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 BEIN Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g entire, east wing, room M. (e.g. Pipe tagging, ailing, plenum SQUARE LINEAR (e.g. running cable. installing fire sprinkler boiler room, lobb . et ducts, storage tanks, dedti , etc. FEET • FEET removing and replacing balers, etc.)

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

NI C l~ Print Nan of App ant (if other than Owner) Pnn Name i As atos Contractor

Signature grtature Signature

32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the performance the asbestos abatement activities in accordance with the Asbestos Control Program Rules. I have contracted the third party monitor who is completely independent of all parties involved in the asbestos project. I hereby declare that I have authorized ing f this notificatio for the rk ecified herein.

. Print Name er r Spnettn Date

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

Any modification of information provided on this form must be reported immediately in writing directly to the NYC DEP 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.

NYC-WTC 000111075