Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler 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) 0 Demolition b) 0 Boiler Replacement c) 0 Sprinkler Replacement d) 0 Renovation/Alteration e) 0 Fireproofing Replacement t) 0 Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure 0 Encapsulation ❑ Repair 0 Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application

.An LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room S. (e.g. Pipe tagging. ceiling. pknum SQUARE UNEAR (e.g. nwvrrg cable, iubllirg fire sprinklers. boiler room, lob , etc) duets, storage tanks. dedmg. etc.) FEET FEET nmovi and rpi ng toilers, eta

1

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.

Pnnt N itor &.me Contractor Print Nam of App ant (If other than Owner)

rtY Signature gnaturo Signature

( - 3- O Date Date Date

32. 1 understand that as the owner of a building where asbestos abatemej.aotivityoccurs. 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 this asbestos project. I hereby declare that I have authorized the

' fill of this notification r the wo specified herein. L —i Print Name of r *S gnatun oa — .:J A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE, AT'T1 E 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. 2/2001

NYC-WTC 000111091