Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

DEP ECB Fax:212-361-1433 Jun 28 2002 11:23 P.02

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler Lo o NYS DEC Permit Tel. $c ^27 ~ ^ ~~ 7 Disposal Site(s) _,QQ11€_2 LE4 es (I t 27. This asbestos abatement is part of a (item a through a requires filing of this forth with NYC Department of Buildings) a) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement • d) ❑ Renovation/Alteration e) 0 Fireproofing Replacement 4 0 Other (Describe) __ ---

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal 'Cl Enclosure ❑ Encapsulation ❑ Repair 0 Clean up

29. ABATEMENT PROCEDURE (Check alt appropriate boxes) ❑ Full Containment 0 Olovebag ❑ Tent 0 PEP Variance Application

1A 1 Af OTION-SAF ABATEMENT ~,~~• T —_D ~~~ - DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM ESCPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e g: shun, aril wing, room A. (e.g. Pipe lagging. ceiling. plenum R (i.e. runn g cable. irulalrtng fire *OMklere. ooaer roan, lobSy. etc) 4oesee lank.. dedunQ. k, SOU RE FEE rernovin and r Eire boiler. etc

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31. I hereby declare that the information provided herein is true and complete to the best or my knowledge. I am familiar with Federal, State and NYC laws and regulations applicable to asbestos related work.

Sc 4 r2 a A ) Print !or Pri Namt Rib toe Contractor Print Ne'n o(Ao ant (it other then Owner)

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of )2, 1 understand that as the owner of a building where asbestos abatement activity occurs. I am responsible for the performance third party air the asbestos abatement activities In accordance with the Asbestos Control Program Rules. I have contracted the authorized the monitor who is completely independent of all parties involved in the asbestos project. I hereby declare that I have filing is notifi lion for the work specified herei . -- -

Sgnsturs Ora Print Nema t Owner WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE OP H P. 1T A ni modification of information provided on this form must be repo-rte.d $mmqdiately in writing directly to the NYC or lessened The requirements of the Asbestos Control Program Rules may not be lawfully avoided through the performance of rk in inerem rite) or piecemeal fashion. t

NYC-WTC 000111148