Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler JESL__ NY _ NYS DEC Permit # 0J — 462 _ Tel.# (718) S 22-2 ZG3

Disposal Site(s) du~E tZIP~E 1--AmCli 1=1 LJ PO Sax 399 Seo -r5 Dv t~E PA I'T 2S4

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

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

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

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

So'3TH 5460 i=ACADE

FACADE Sc to t 26 276 (G¢G C

fACADF. t4ocii4 20000) FACADE s'c iSoc>a

FACE. D. CumT 11 TOO FLUE ( 1Nstoa c ' 2400

F$2 E-SCAFNE5 %6S0 Duct t..o 4 Ale. 0441S 960 5e•T cF 1i 25

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.

kR/ZEit _ / ()/Z W o- Print N e of Air Mon' r Prin7Name sbesto ontractor Print Name of Applicant (If other than Owner)

Signature Signature

Signaturees ~1 —~ Z~ — —_ ~✓ U .1.~ --- Date -- Gate 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. _ oGl+ t~4 (02. Signature Date Print Name of Owner WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE DEP ACP. [Any modification of information provided on this form must be reported immediately in writing directly to the NYC lessenea The requirements of the Asbestos Control Program Rules may not be lawfully avoided or through the performance of work in incremental or piecemeal fashion. *car 2200+

NYC-WTC 000111290