Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler 1ESti N y -- ___ NYS DEC Permit # NJ - 462 __ Tel.# (1 tl3) g22. 22.3

Disposal Site(s) DE PA 0Grc LANDFILL P0 BOX 399 Sc.OTSDALE 'PA 11254

27 This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) 0 Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) 0 Renovation/Alteration e) 0 Fireproofing Replacement f) 0 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 ❑ Glovebag ❑ Tent ❑ DEP Variance Application

aA 1 ^I%ATIAIJC AF ARATCUCkIT ii .. a 9'y3~lk o2/ DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION O WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e 9• entire, east wing, room #, lagging. (e.g. Pipe 99 n9• plenum 9. ceiling, SQUARE LINEAR (e.9 running cable. installing fire sPnnklers, FEET FEET removing and replacing boilers, etc.) boiler room, lobby. etc) ducts, storage tanks, decking. etc.) NO2 t=ACA.O FAGAVE (I=VLTON STET) A410

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.

t*JAfwtclJ 4"PAuz N&1 Sold QD, _ runt Name of Air Monitor Print Name of Asbestos Contractor Print Name of Applicant (If other than Owner)

Signature ,. Signature Signature

_ 6- PZ- a 3~C Date Date Date

of 32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the performance air accordance with the Asbestos Control Program Rules. I have contracted the third party 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.

Date Print Name of Owner Signature WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE to the NYC DEP ACP. Any modification of information provided on this form must be reported immediately in writing directly or The requirements of the Asbestos Control Program Rules may not be lawfully avolaea throuah the performance of work in incremental or piecemeal fashion. ACP7 2/2001

NYC-WTC 000111272