Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler IESI,NY NYS DEC Permit # NJ-462 Tel.# (718) 522-2263

Disposal Site(s) BlueRidge Landfill 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) ❑ Renovation/Alteration e) O Fireproofing Replacement f) 0 Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) O Full Containment O Glovebag O Tent O DEP Variance Application '.. /'r _—' fr o' /(f/~ /~ o: /

30 tflATlflIIS AF ARATFIk1FNT P c c F #,I ATrc"Tz-r A [_ ; ROOF E.

DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room N. (e.g. Pipe lagging, ceiling, plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers. boiler room, lobby, etc) ducts, storage tanks, decking, etc.) FEET FEET removing and replacing boilers. etc.)

FACADE (Lcust:ti` ¢Core ($~~ w RCO F PARA PeT L EDEN E TO tt PAf2APET WALL 584

ROOF Se. FACE l O

FACA (VPPEa floop) 1540 ff =aC0F= RcoF riot.FAC..' IS 84 tt 0ct-c f.tG .l AOU DOCcr wc:l2a 304 Ala. UNIT5 ('2) 800

r PAaAP4.T 332

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.

Prin .IQ me of Air nitor r Print Name of Asbestos Contractor Print Name of Applicant (If other than Owner)

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Signature Signature

— ate 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. _ _ Signature D~_ ~I~ IO2 Oate Print Name of Owner

A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.

I 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 2!2001

NYC-WTC 000111288