Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

DEP ECB Fax:212-361-1433 Jun 28 2002 11:25 P.05

ASBESTOS INSPECTION REPORT 28. Asbestos Hauler NYS DEC Permit tf 12__ Tel.ij). Disposal Site(s) 27. This asbestos abatement is part of a (Item a through a requires filing of this form with NYC Department of Buildings) e) ❑ Demolition b) ❑ boiler Replacement c) ❑ Sprinkler Replacement d) Q RenovationlAtteretion a) ❑ Fireproofing Replacement I) ❑ Other (Describe) __ _ --____---------__________- 28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure 0 Encapsulation ❑ Repair 0 Clean up

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Applicatio 3O. LOCATIONS OF AIIATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF AC DESCRIPTION OF WORK BEING vt Floor(s) I OF FLOOR CONTAINING ACM PERFORMED (e.g. anti,.. eat wring. room 0, (e.g. Pipe logging, toiling, pNnum SQUARE LINEAR (e 0. running cable. installing fire apnnkiers, Ilsr room, lobby, sic) ducts, itong. tanks asok' . etc.) FEET - FEET r.movine and r.5iaCis bat eta

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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.

Prot Nameor7GTwbgitor P • Namur 1104 Contractor _ Pin; Nan of ApC y' c rat (II other then Owner)

Signaturs gnaturs s:gneture ~~++ ate- p3-o~ 32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the performance airof the asbestos abatement activities in accordance with the Asbestos Control Program Rules. I have contracted the third party monitor who is completely independent of all parties involved In the asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein..

Siynelvre Oct,. Pfint Nana Of Owner ---- WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE to the NYC DEP ACo. rAny modification of information provided on this form must be reported immediaet in wrilino directly

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NYC-WTC 000111173