Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler LO _ NYS DEC Permit LTO go 70-3& ? Disposal Site(s) ©_v I R! e2 JP /( eN ies~ A 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) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement f) ❑ Other (Describe) __ __ ----------------

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application ']A 1 ^1 1 AT1/1\1C f1C AO ATC1IC\IT

DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SQUARE LINEAR (e.g running cable, installing fire sprinklers. (e g. entire, east wing, room #, (e.g. Pipe lagging, ceiling, plenum FEET boiler room, lobby. elc) ducts, storage tanks, decking, etc.) FEET removing and replacing boilers, 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 Federal, State and NYC laws and regulations applicable to asbestos related work.

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Pnnt N 1r itor Prin Name f Asb stos Contractor Print Nam of App cant (If other than Owner)

Signature gnature Signature

Date Date 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 filing of thi$ notification for the work specified herein — —

— Date r Print Name of Owner Signature

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. III lessenea The requirements of the Asbestos Control Program Rules may not be lawfully avoided or rhrry ,nh tha narfnrmanca of work in incremental or oiecemeal fashion. ACP1 2/2001

NYC-WTC 000111101