Asbestos Project Notification form, Corona NY

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler SES LN Y NYS DEC Permit # IW -462 Tel.# (Itg 522 - -226 2 Disposal Site(s) _BLUE 1ZtD6,E LAWD FIL%.. p o BOX 399 SCOTSDAt PA l72

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) 0 Renovation/Alteration e) ❑ Fireproofing Replacement f) ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) 0 Removal 0 Enclosure 0 Encapsulation 0 Repair 19 Clean up

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ~~ ~ ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application 1/1'

30. LOCATIONS OF ABATEMENT QOOF MATERIAL t STONES C.04 (a1 R.00F MEMB¢ANIZ DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room p, (e.g. Pipe lagging, ceiling, plenum SQUAP}E LINEAR (e.g. running cable, installing fire sprinklers, boiler room, lobby. etc) ducts, storage tanks, decking, etc.) FEET FEET removing and replacing boilers, etc.) At ROOF ROOF SVRFAG . 18880 Srt3ats coveW04 R4oF weusmmE ft Louv UiA-LL 1750 it Meru 500 ABC uNtT Mt=TArt SvPPotttS RooF ROOF S32t=ACE 1216 SMALL ttooFs F Sara-AcE 79q 5 (NDivlDVAL SMAu,Ee QAocs

Ale UNlr S.'PPC2TS Q17 METAL A/C. SJPpoRfS

SOL UEA0 180

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.

WAQRENwPAg2e E" lNt -T25 1- kVQzI3AN 4 So 4 COta OL Pnnt Name of Air Moni or Print N me of Asbestos ntracto Print Name of Applicant (If other than Owner)

Sign lure Signature Signature

o1 -1'2-c2 _ __ OT-12-n2 _ 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 t this notification for the work specified herein. - _ NYC DEP ez- f 2 -02 Print Name of Owner Signature Date

"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 directly to the NYC DEP ACP. 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 2/2001

NYC-WTC 000111254