Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) •

26. Asbestos Hauler LO i7 ~~• NYS DEC Permit If _COIg ' Tel, 8'~t 272 3 6fc rr 7 4. Disposal Site(s) U eQ lE e4 \J*((7 ' ~'(', 27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of/ a) 0 Demolition Buildings) b) 0 Boiler Replacement c) 0 Sprinkler Replacement d) 0 Renovation/Aiteration • e) 0 Fireproofing Replacement t) 0 Other (Describe) 28. TYPE OF ABATEMENT (Chec k all appropriate boxes) ❑ Removal 0 Enclosure 0 Encapsulation 0 Repair 0 Cleanup 29. ABATEMENT PROCEDURE (Check all appropriate boxes) . ❑ Full Containment . ❑ -Glovebag 0 Tent 0 DEP Variance Application 30. LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES Floor(s) OF FLOOR AMOUNT OF ACM DESCRIPTION OF WORK BEING (e.g. entire, east wing, room 0, CONTAINING ACM (e.g. Pipe tagging, ceiling, plenum SQUARE LINEAR PERFORMED bailer room lobby, etc) ducts, ',FEET. • (e.g. running able. installing foe Sprinklers, tanks. . etc. FEET .eninSJi and bolas, etc As c..j o0

31. I hereby declare that the information provided herein is true and complete to the best of my knowledge. I State and NYC laws and regulations aooticable to asbestos ralatarl wnr4 am familiar with Federal,

Pint N o 'tor 5i P ' Name r Asbestos Contractor (l Print Nam of App nt (If other than Owner) p

Signature nature Signature

Date Date Date 32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the the asbestos abatement activities in accordance with the Asbestos Control Program Rules. I have contracted the performance of monitor who is completely independent of all parties third party filin f involved in the asbestos project. I hereby declare that I have authorized air otification for works ecified herein. the -__ PL ;n1tN—ame of owner T7Ja• oL Signature Oat 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 06P 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. ACP7 212001

NYC-WTC 000111097