NYC 9/11 Public Portal Document
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ASBESTOS INSPECTION REPORT (continued) "
26. Asbestos Hauler _. OF nyo NYS DEC Permit ar Tel go> -272~386?
Olsposal Site(e) Soolu ek i l E g hen i= ° 7 ft ef F i
wires filing of this form with NYC Oepertment of Bulidings)
«) 0) Renovation/Akeration
alee
27. This asbestos abatement Is part of 6 (Item a through e req
a) (J) demotition b) O Botter Replacement ¢) Oo Sprinkler Replacement
e) 0 Fireproofing Replacement 4 D0 other (Describe)
28. TYPE OF ABATEMENT (Check all appropriate boxes)
Wasemevd CLenqopure (3 Encapgutation OO Renair_ , C1 ctean up —
. oy OR GE ra
eramsrses
29. ABATEMENT PROCEOURE (Check all appropriate boxes)
CD Fult Containment OC) ciovebeg () tent Cl vee Variance Application TZ
| ~- (006 Hur
40. LOCATIONS OF ABATEMENT.
Se eT DESCRIBE SECTION | AFFECTED SURFACES AMOUNT OF ACM ‘DESCRIPTION OF WORK BEING |
Floor(s) FFLOOR CONTAINING ACM
oe 9, Pice eggi L psquane = WEAR | eg. ble, fre sorinuters,
nasa nithe mons. | ga.reamoncomperes| Vieer Wiebe | “Sarmmasetenetntes a
Ee 2 si loge 4 le
PERE
31. [hereby declare that the Information provided herein is true and complete to the best of my knowledge. | am familar with Federal,
State and NYC laws and regulations epplicadle to asbestos related wark.
——" mae
Facsun € Bu ntated Hlhgey ( oSiA Aid fren Cesiz
Pan Name gt Asbestos Contractor Print Name of App! Cand
Pant
i } te . CinLG ae
Signeture nature
OO \0Z-02, | _ G-3-0 G+ 3-02
~~ Dats Bate Sate
32. tunderstand that as the owner of a bullding where asbestos abatement activity occurs, | am responsible for the performance of
ca wih the Asbestos Control Program Rules. | have contracted the third party air
the asbestes abatement activities in accordan ‘
monitor who is completely independent af all parties involved in the asbestos project. | heraby dectare that | have authorized the
filing of this ~p for the work specified herein.
Oate
AT THE WORK SITE.
Print Name of Owner 4 Signature
: A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE
in writing directly to the NYC OEP ACP.
Any modification of information provided on thi form must be reported immedia
The requirements the Asbestas Control Program Rules may nol be lawtully avolded or lessened
through the performance of work in Incremental of piecemeal fashion. ae)
NYC-WTC_000111110
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000111110Source: NYC Law Department, mirrored locally