Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler_CC JO NYS DEC Permit —~ t Tel. Disposal Site(s) O e2N t,E e5 * 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) 0 Removal 0 Enclosure 0 Encapsulation 0 Repair 0 Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag 0 Tent ❑ DEP Variance Application /~ 30. LOCATIONS OF ABATEMENT 14000 {, Y DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACl DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room U. (e.g. Pipe lagging, ceiling, plenum SQUARE LINEAR (e.g. running cable, installing tire sprinklers. boiler room, lobby, etc) ducts, storaQe tanks, ddin0. etc.) FEET ' FEET removing and repIadnc boilers, etc.) .00 F- X300

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.

V SL rr Print N r c C ~t f t QY.~ itor /v~ U7~ c1 Prin Name I Asbestos Contractor 7 2 37 f' Print Nam of App ant (If other than Owner)

Signature nature U Signature -3 —02 • . . , 3-~Z 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 her y declare that I have authorized the filing oAthis notifi ion for the work specified herein. r ry Print Name of Owner Signature Date

STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. r i An ' odification of information rovided on this form must be reportedimmediately 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. I r moot

NYC-WTC 000111154