Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler Co _<..( 1AJO NYS DEC Permit -o t Tel. O ' ^ 27?- 3& , Disposal Sites) C) e2N]l1q se 5 ( f

27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement f) ❑ 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 3O LUCOTlfNs nP AaATeur.rr DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM (OO?/fk o: ESCRIPTION OF WORK Floor(s) OF FLOOR ING (e 9. entire, east wing, room p, CONTAINING ACM PERFORMED (e.g. Pipe lagging. ceiling, plenum SQUARE (e.g. running cable, installing rive sprinklers, boiler room, lobby, etc) ducts. storage tanks, decki . etc.) EET LINEARNEA removing and replacing boilers, etc.

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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.

Pint N r itor cv ' il /,j/ a141 Prin Name 1Asbestos Contractor Pnnt Nam of App ant (if other than Owner)

Signature gnature Signature 03 op 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 h reby declare that I have authorized the filing of INnotificati for the work specified herein.

Print Name of net Signature Date A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. An 'modification of information provided on this form must be reported immediately in writing directly to the NYC DEP ACP. The requirements of may not be lawfully avoided or ACPI

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