Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document III NASSAU JTlztctc

ASBESTOS INSPECTION REPORT (contltnued) '" 4l 26. Asbestos Hauler IESI.NY NYS DEC Permit # NJ-462 ;el.# (718) 522-2263

Disposal Sites) BlueRidge Lard" 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) 0 Renovation/Afteration e) ❑ Fireproofing Replacement f) El Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ~ A 0 Full Containment 0 Glovebag 0 Tent 0 DEP Variance Application -tom v

30. LOCATIONS OF ABATEMENT OOF ME146RANE (TAr- DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room M. (e.g. Pipe lagging, ceiling, plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers, boiler room. lobby, etc) ducts, storage tanks, deding, etc.) FEET FEET removing and replaang boilers, etc.)

eOOF ROOF Su"Ac.E 3942 tt PAeAPE-r L At.L 4'- 6e IT6 11 A/C VNtfS 4 METAL 5000 FACADE t4S5SMi Sr. FNCADE (EM 2295

WNING 6T2 tt W l 1400u . 6 12

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.

idLttttElJ PA►.126t EA4iNEE12S Print Name of Air Monitor -i Ab1It.1 Print Name ~Asb kURZBAN of 4 SOO Corr Contractor estos ____—

Print Name of Applicant (If other than Owner)

` Signa Signature Signature

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. 06 126 102 Print Name of Owner ignature 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. ACPr moot

NYC-WTC 000111268