Asbestos project notification form, Zone I Originals

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ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler NYS DEC Permit 7 Disposal Site(s)

27. This asbestos abatement Is part of a (Item a through a requires filing or. this form with NYC Department of Buildings) a) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement • d) 0 Renovation/Alteration e) ❑ Fireproofing Replacement f) ❑ Other (Describe) ____

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 t3lovebag 0 Tent ❑ DEP Variance Application / O`/ fl 30. LOCATIONS OF ABATEMENT / [ o y DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM bECRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g anti.. east wing. roan M. (e.g. Figs lagging citing. Plenum SQUARE LINEAR (e.g. running cable, lnrtalling Ere sprinklen. baler roam lobby. alt) duCts, lion tanks. decd FEET ' FEET r.n1osnand lnQ boil

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31. I hereby declare that the Information provided heroin 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.

Pmt itor ' Nehw As to Contractor Print No of App nt (N other then Owner)

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32. I understand that as the owner or a building where asbestos abatement acWlty occurs, I am responsible for the performance of the asbestos abatement aotivldes 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 fiUng,of this notj5ca(ion for the work specified herein.

d` Print Name d Owner mo ~siynaturo 1 ogle

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 directlyto the NYC DEP ACP. The requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened through th Dsrfermance of work In Incremental or piecemeal fashion. nePr at

NYC-WTC 000111196