Asbestos Project Notification Form, 111 [name]

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler 1ESIi tJ Y -- _ NYS DEC Permit # _#3.1-462 _ Tel.# (i 1S) S22-2263

Disposal Site(s) 6LUE Q.4 D LAODFtLL PO BOX S99 S COTS OALr_- TA 112 S4

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) 0 Sprinkler Replacement d) 0 Renovation/Alteration e) ❑ Fireproofing Replacement f) 0 Other (Describe) _—~-- ----------

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 Glovebag ❑ Tent ❑ DEP Variance Application

30 LOCATIONS OF ABATEMENT -A a DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION 0P WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. Pipe tagging, ceiling, plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers, (e.g. entire, east wing, room #, boiler room, lobby, etc) ducts, storage tanks, decking. etc.) FEET FEET removing and replacing boilers, etc.) NOQ.fl. AGAO t=AADE (PVt_TON S,QE'~T) 4410

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.

4"PAW ZERt N61 nl E'EItS BE J M I to ti11226RN f SO►3 (j,u, _ W rDEP Lrint me of Air Monitor Print Name of Asbestos Contractor Print Name of Applicant (If other than Owner)

t/ / Signature ~ i ~. .r Signature _ Signature

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 accordance with the Asbestos Control Program Rules. I have contracted the third party air the asbestos abatement activities in 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. 6( $ 02 Signature Date Print Name of Owner --

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

NYC-WTC 000111274