Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continue„ 26. Asbestos Hauler NYS DEC Permit ¶ ga,-Z72-3 7 L) 1 II elC,' 1I, (F. ' ( ' I _. a+ " ' — - ' Disposal Site(S)

27. This asbestos abatement is part of a (Item a through to requlr b~ ' F this form wIth NYC Department of Buildings) n9 •rl'..'A ~i= a) ❑ Demflition — b) QBoiler Replacement ~ -c) ❑ Sprinkler Replacemeft •, d) ❑ Renovation/Aferation _ . Sr" e) ❑ FireproofrtgRepi cgrnent .f) ❑ Other (Describe)'—'

28. TYPE OF A'1' J fENT`(Check all appropriate boxes) • ' ❑.Removal ❑ Enclosure ❑ Encapsulation ❑ Repair D deanup - 29. ABATEMENT PROCEDURE tCheck all appropriate boxes) — ❑ FuII Containment.. ❑ Glovebag ' ❑ Tent 0 DEP Variance Application na'. w - .a.,l. A! 1S-Tl-..e..T JV. _P PS I r6/r yr non I W.MW_ IJ

DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SQUARE LNEAR (e.g nsv*ig able. installing 6s sprinklers, (e.g entire. east wing. room a. (e.g. Pipe rigging. paling. Plenum FEET baler room. , at ducts, stoce tanks . etc. SET' tsmovng and r.plang twiNrs, etc

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3] I hereby dectat'.e that the information provided herein is true and complete to f best of my`krtuwledge.:I am familiar wrth Federal, j ; Statea NYg4aws and regulations applicable to asbestos related work-- :. 'i

. Print nor i r&vuv Name Contractor Pnnt Nan or App . nt (M other than Owner)

Spnah" nature Spneture

- Date Oat* Gate

the performance of 32. 1understand that as the owner of a building where asbestos abatement activity occurs. I am responsible for party air the asbestos abaement activities in accordance with the Asbestos Control Program Rules. I have contracted the third monitor who is completely independent of all parties involved in the asbestos project. I hereby declare that I have authorized the ing f this notificatio for the rk ecified herein. ` P~ 3 01- _~ - •• Oat. __Pmt tvame THE WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS•MUST BE AVAILABLE AT to the NYC DEP ACP. Any modification of information provided on this form must be reported immediately in wntino directly requirements of the Asbestos Control Program Rules may not be lawfully avoidea or

NYC-WTC 000111083