Asbestos Project Notification form, Corona NY

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler i ES i, ._._ NYS DEC Permit ft MA - _ 6? • __ Tel.# (its) S2212263

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

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) /~ 0 Full Containment ❑ Glovebag 0 Tent ❑ DEP Variance Application "7i

30 I.flATIONSOFARATFMFNT P-COF= MArTukc. : RGCF ( T/.R ) 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 N. (e.g. Pipe lagging, ceiling, plenum FEET ' FEET removing and replacing boilers. etc.) boiler room, lobby. etc) ducts, storage tanks, decking, etc.)

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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.

u;AR¢Ea► T ~(~N2a~t C —NE;la~ctzs_ __ f,#A%M ezr A4 S yCh L Print Name of Air Monitor Print Name of Asbestos Contractor Print Name of Applicant (If other than Owner)

Signature Signature Signature

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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 th asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein.

Signature Date Print Name of Owner

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

NYC-WTC 000111234