Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document DEPECB Fax:212-361-1433 Jun 28 2002 11:23 P.03

ASBESTOS INSPECTION REPORT (continued) --'Z7Z^3' ? 28. Asbestos Hauler_OC UO NYS DEC Permit Tel. . ~~

Disposal Sites) !122 1E e S

27. This asbestos abatement is part of a (item a through a requires filing of this form with NYC Department of Buildings) a) a Demolition b) ❑ Boiler Replacement o) ❑ Sprinkler Replacement d) ❑ Renovation/Altenstion a) ❑ Flreproofing Replacement t) ❑ Other (Describe) - _ -

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application _/a '? JV ~vvfl"v,DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SOUARE UNEAR (e.g. nrnr;JnQ awWe. iredalling fire aprinkltrs, (e4 entire. east vmg. room M. (e.g. Pip. IOggUg, !Wino• pterwm FEAT rotler room lobby, et lion e ntt edUflQ. .Ic.i FEET ' remodnp and reaeM boaerc sec.)

familiar with Federal. 31. 1 hereby declare that the Information provided herein is true and complete to the best of my knowledge. I am State and NYC laws and regulations applicable to asbestos related work.

P Name As s contreckar 4 PM(Ne of App d & nt (If other than Owner)

!tore • 9tgneWrt Signature

32. i understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the performance of Program Rules. I have contracted the third party air the asbestos abatement activities In accordance with the Asbestos Control I have authorized the monitor who is completely independent of all parties involved In the asbestos project. I hereby declare that filing o/(~thIs notification for the work specified herein'

Signature wu Print NmJ of Owner THE WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT [Anymodification of Information provided on this form must a re rted imme tel In writi direr to the NYC DEP ACP.

The requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened trOuh the performance of work in incremental or piecemeal fashion. ACP?

NYC-WTC 000111150