Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler LC JC NYS DEC Permit f _ Oc( . Tel.# n/ / . 11r Disposal Site(s) U( €2F'..) 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) ❑ Boiler Replacement c) 0 Sprinkler Replacement d) 0 Renovation/Alteration e) 0 Fireproofing Replacement f) 0 Other (Describe) _ -

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal 0 Enclosure 0 Encapsulation ❑ Repair ❑ Cleanup 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent 0 DEP Variance Application 30. LOCATIONS OF ARATFMFNT A w ~ /)!// y/ AIIA 7 DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF W RK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room p, (e.g. Pipe tagging, ceiling, plenum SQUARE LINEAR (e.g running cable, installing rite sprinklers, boilerroom, lobby, etc) ducts, storage tanks, decking, etc.) FEET FEET removing and replacing boilers. etc.)

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

4M tt 377 U7~ ' Pint N ~r itor Prin Name r As stns Contractor Pnnt Nam of App .ant (If other than Owner)

Signature gnature Signature

O~- 03 - o 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 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 declare that I have authorized the in otificatio for the work specified herein. , I) Q~"S' ame of net Signature Date •tiAA•• r STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.

l Anr . 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. I ACP7 2/200+

NYC-WTC 000111085