Asbestos Project Notification form, Corona NY

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 13 26. Asbestos Hauler tESt , Ny NYS DEC Permit #_4i - 462 Tel.# (118) 522-2363 ~e-

DisposalSite(s) BwrsR.~DGE LM.IDFII.L PO BOX 399 ScotsoAka P. 11254

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) 0 Boiler Replacement c) 0 Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement f) ❑ Other (Describe) —

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 Glovebag 0 Tent ❑ DEP Variance Application en I A/ 1 ATI i.IQ AC AQATCIIC►IT JV. rV Vr+V ~V v ,

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 SQUARE LINEAR (e.g. running cable, installing fire sprinklers. FEET FEET removing and replacing boilers, etc.) boiler room, lobby, etc) ducts, storage tanks. dedcin , etc.)

FACADE joNN ST. FACADE F .CAD ts: Su.z.FACES 63Oo RO aooe -ro ST¢£e-r

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.

WNW t PANZER eW,..l. E s B. ,ug.28A/3 i SON CONTROL Print Name of Applicant (If other than Owner) Print Name of Air Monitor Pri t Name of Asbestos C

Signature Signature Signature

OT-12-02. 01-12-02 Date Date Date

performance of 32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the accordance with the Asbestos Control Program Rules. I have contracted the third party air the asbestos abatement activities in authorized the monitor who is completely independent of all parties involved in the asbestos project. I hereby declare that I have filing of this notification for the work specified herein. N OT -12-02 Signature Date Print Name of Owner WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE NYC DEP ACP. IIII Any modification of information provided on this form must be reported immediately in writing directly to the I The reauirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened in ACP? 2f001

NYC-WTC 000111232