Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document N ASSAU S'C2>~c'r / 12.9 Rit rotJ S -r ASBESTOS INSPECTION REPORT (oondnued)

26. Asbestos Hauler IESIIIY NYS DEC Permit # NJ-462 Tel.# (718) 522-22,63 Disposal Site(s) BlueRidge Landfill PO Box 399 Scotsdale, Pa 17254

27. This asbestos abatement is part of a (Item a through a requires filing of this form with NYC Department of Buildings) a) 0 Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑,Renovation/Atteration e) ❑ Fireproofing Replacement f) El Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) , / .L 0 Full Containment ❑ Glovebag 0 Tent ❑ DEP Variance Application 8- ~ •M {

An LOCATInNS AF ARA mA MT D.- , c ►a aM F 1a tDA.a1G E TAB' 1 DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g entire, east wing, room ir, (e.g. Pipe lagging, ceiling, plenum SQUARE LINEAR (e.g running cable, installing fire sprinklers. boiler room, lobby, etc) ducts. st tanks, decking. etc.) FEET FEET removing and reptaang boilers, etc.) __ ROOF SuaFA 7000 tt -PAizo t>€S 461 tt G U -fi-tzs 1( 4 FAc.a c 2345 It t~~c uNts METAL 23TO

31. 1 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.

~ANZEDC3n I13 Dt'111M_Mta J&ZBAt4 S0ti Print Name of Air Monitor Print Name of Asbestos Contractor Pnnt Name of Applicant (If other than Owner)

natur Signature

aa fD roz Signature

_ Gate 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.

~Ep 06 126 102 Print Name of Owner Signature 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. ACP7 2rtoo1

NYC-WTC 000111278