Asbestos project notification and inspection report form

NYC 9/11 Public Portal Document

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ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler NYS DEC Permit !f TEL# Disposal Site(s) 27. This asbestos abatement Is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) 0 Demolition b) 0 Boiler Replacement e) ❑ Sprinkler Replacement d) 0 Renovation/Alteration e) 0 Fireproofing Replacement 1) ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair ❑ Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) 0 Full Containment ❑ Glovebag 0 Tent ❑ DEP Variance Application 30. LOCATIONS OF ABATEMENT DESCRIBE SECTION I AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing. room 0. (e.g. Pipe lagging, ceiling, plenum SQUARE UNEAR (e.g. running cable, installing fire sprinklers, boiler room. lothy, etc) ducts, storage tanks, decking, etc.) FEET FEET removing and replacing boilers, etc. )

oof Item No. 2 3250

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.

arren & Panzer Trio Asbestos Removal NYC Print Name of Air Monitor Print Name of As tos Contractor Print Name of Applicant (If other than Owner)

Signature Signature Signature

Date qS Oate 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 sbestos trol Program Rules. I have contracted the third party air monitor who is completely independent of all parties inv v d i th es s 'e t. I hereby declare that I haveTathorized the filing of this notification for the work specified here Time Equities C/o NYC bZ Print Name of Owner Signature ate A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.

I Any modification of information provided on this form must be reported immediately in writing directly to the NYC DEP ACP. requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened ACP through the performance of work in incremental or piecemeal fashion. 212001

NYC-WTC 000111222