Asbestos Project Notification form, Corona NY

NYC 9/11 Public Portal Document

►56 W I t_LI A NA S'Tlz'eET ASBESTOS INSPECTION REPORT (continued) ~` 26. Asbestos Hauler IESI,NY NYS DEC Permit # NJ-462 Tel.# (718) 522-2263 Disposal Site(s) BlueRidge Landfill PO Box 399 Scotsdale, Pa 17254

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) ❑ Re'novation/Aferation 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) 1/ll~le r,1 0 rZ ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application

30. LOCATIONS OF ABATEMENT (2OOF LAA'rGO.A► . . •ro . At f\ nf7 cn,..~. DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM (e.g. entire. east wing, room C. SQUARE PERFORMED (e.g. Pipe lagging, ceiling, plenum LINEAR (e.g. rtmning cable, installing fire sprinklers, boiler room. lobby, etcl ducts storage tanks. decking, etc.) FEET FEET reagying and regleang boilers etc roP fZc0ct^ Ot= 5U¢FAC 5681 . reo ER ftpvF SuCAL'E 525 It METAL LOO 74o It Wtuoota &GOGE 16 L. Roos E suet=o. c`~'— 3354 AC uur O-OOF toot= Su I914

31. 1 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.

1OAtttt13~AqZ R ElA1E:s11)Etr1Zs B. VAM zaAN S SON CoNM0L nt Name of Air Monitor Print Name of Asbestos Contractor Print Name of Applicant (If other than Owner)

i9naturf Signature ----- Signature

06 13002 06 (30 l d2 Date Date _ Dale

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.

Prim Name of Owner Signature Nyt'' DEP tt:1E+ I3 s IOZ Date A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. 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 ACP7 2!2001

NYC-WTC 000111258