Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) o 26. Asbestos Hauler NYS DEC Permit Sf CTO1R' ~OC> Tel, Disposal Sites) ~DU~ e2N tE 5 ( ~1(' 27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) 0 Demolition b) ❑ Boiler P Replacement c) ❑Sprinkler Replacement i d) ❑ RenovatioNAlteration' ' e) ❑ Fireproofing Replacement f) ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair • 0 Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag 0 Tent ❑ DEP Variance Application 30. LOCATIONS OF eaereurkr DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM Floor(s) OF FLOOR DESCRIPTION OF WORK BEING CONTAINING ACM PERFORMED (e.g. entire, east wing, room p, (e.g. Pipe lagging, ceiling, plenum SQUARE LINEAR boiler room, lobby, etc) (e.g. running cable, installing fire ducts, Storage tanks, decking, etc.) FEET FEET sprinklers. removing and replacing boilers, etc.) 00 3~ ift 3Et Gtr 15It S C 4 GrpQ -,t 0 S sCJ& ç Ct rou3 0~ I

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.

7 St~~ LEFt/~Lr4PtC Pnnt N ,)f 7 it ita Prin Name Asbestos Contractor Print Nam of App ant (If other than Owner) r Sgnature gnature Signature

Date Date Date 32. 1 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 filing of.•this notification for the work specified herein project. I hereby declare that I have authorized the __~ ti Print Name of er y' Signature Date ffr1' . S~'~~MPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. \ I kny moolrlcatloa or information provided on this form must be reported immediately in writing directly to the NYC DEP ACP e requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened : ? ~; p through the performance of work in incremental or piecemeal fashion. I Ac~r 2/2001

NYC-WTC 000111115