Asbestos Project Notification form, Corona NY

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler _11E51 ` Nv __ __,-- NYS DEC Permit # u-1-462 ___ Tel.# (118) 522- 226 3

Disposal Site(s) t ie e1D~E~~~~u PO BOX_ Scc 1so/4 PA_ IT254 f

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 c) 0 Sprinkler Replacement d) 0 Renovation/Alteration e) 0 Fireproofing Replacement f) 0 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

9A 1 AI ATIANCr1EABATEMENT ROOF MA1'E1t-4 At- , QAOF MEMBRANE (TAR) DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SQUARE LINEAR (e.g. running cable, installing fire sprinklers. (e g. entire, east wing, room If. (e.g. Pipe lagging, ceiling, plenum FEET boiler room, lobby, etc) ducts, storage tanks, decking. etc.) FEET ' removing and replacing boilers. etc.)

2oOF ROOF SvR.FACE 1I66 A.u.. ROOF 5uacAcE5

gut. 1AE-A.o 1092 Pry aptT 12 3'lr

R!C 4 Do csS 1900 U.

F1Q. EgCs.PE 6 C.A4E 450

of (r1TEto2 Fi4CAC-S 6590

It D. 1 c COPE S•JR-GACE 21 30

4 Noll_ l_ ___ Sue- 'e-E 0

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.

tNA¢O~N @ PANZM CW-4101 ERs 'g. iGu¢2SAN l Sot CT24L Print Name of Air Monitor Pri Name of Asbestos Contractor Print Name of Applicant (If other than Owner)

Signature Signature Signature

-12-02 __ 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 this notification for the work specified herein. _ ls/C_oEP o7-12-V 2 . — Signature Date Print Name of Owner

A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. ACP. Any modification of information provided on this form must be reported immediately in writing directly to the NYC DEP The requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened through the performance of work in incremental or piecemeal fashion. ACP7 212001

NYC-WTC 000111250