Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) l' NYS DEC Permit # _ -462 Tel.# 26. Asbestos Hauler (ESS . t UE 121 E LA~+DFI ILL PO BOX 3 oT 5 D AL A Disposal Sites) Buildings) 27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of •a) ❑ Demolition b) O Boiler Replacement c) ❑ Sprinkler Replacement • d) ❑ Renovation/Alteration

e) O Fireproofing Replacement f) O Other (Describe) — -- -

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

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

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

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am familiar with Federal, 31. I hereby declare that the information provided herein is true and complete to the best of my knowledge. I State and NYC laws and regulations aoolicable to asbestos related work. Zic- c i J'.

Print Name ofAir Monitor Print a of Asbestos C tractor Print Name of Applicant (If other than Owner)

Signature Signature Signature

O to Date Oate

responsible for the performance of 32. I understand that as the owner of a building where asbestos abatement activity occurs, I am the asbestos abatement activities in accordance with the Asbestos Control Program Rules. I have contracted the third party air independent of all parties involved in the asbestos project. I hereby declare that I have authorized the monitor who is completely filing of this notification for the work specified herein. ct,r' 456114'402 Signature Date Print Name of Owner AVAILABLE AT THE WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE in writing directly to the NYC DEP ACP. I Anv modification of information provided on this form must be reported immediately avoided or lessened The requirements of the Asbestos Control Program Rules may not be lawfully through the performance of work in incremental or piecemeal fashion. ,got

NYC-WTC 000111292