Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

. I. j

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler LO NYS DEC Permit —~ Tel.

Disposal Site(s) JQU 1 i

27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) O Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) O Renovation/Alteration e) ❑ Fireproofing Replacement f) O Other (Describe) _

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) O Full Containment O Glovebag

An LOCATIONS OF ARATFMFNT DESCRIBE SECTION ❑ Tent O DEP Variance Application

AFFECTED SURFACES AMOUNT OF ACM oyes~i DESCRIPTION OF WORK SING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e g. entire, east wing, room p, (e.g. Pipe togging, ceiling. plenum SQUARE LINEAR (e.g running cable, installing fire sprinklers, boiler room,lobbby, etc) ducts, storage tanks, decking, etc.) FEET FEET removing and replacing boilers. etc.)

S St

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.

sC1rt t•t ~(~.! Mt _ _ I ~vGv C Pnnt N it 'tor Prin Name f Asb stns Contractor Print Nam of App ant (If other than Owner)

rY ______ ____

Signature gnature Signature

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 hereby declare that I have authorized the filing of t notifi ,n for the work specified herein. pp

Print Name of Owner Signature Date

A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.

Any modification of information provided on this form must be reported immediately 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 oerformance of work in incremental or piecemeal fashion. Acaz'

NYC-WTC 000111152