Asbestos Project Notification Form, DEP Box 39

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ASBESTOS INSPECTION REPORT (continued) NYS DEC Permit # NJ-462 Tel.# (718) 522-2263 26. Asbestos Hauler IESI,NY Pa 17254 Disposal Site(s) BlueRidge Landfill PO Box 399 Scotsdale, Department of Buildings) 27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC b) 0 Boiler Replacement c) 0 Sprinkler Replacement d) 0 Renovation/Afieration a) 0 Demolition e) 0 Fireproofing Replacement f) El Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent 0 DEP Variance Application e✓ toot✓ -1A'1"~RaA(-' C "rE,/ i~' ' _— V ~~v 30. LOCATIONS OF ABATEMENT DESCRIPTION OF WORK bEING DESCRIBE SECTION AFFECTED SURFACES I AMOUNT OF ACM CONTAINING ACM PERFORMED Floor(s) OF FLOOR SQUARE LINEAR (e g. running cable, installing fire spnnklers, (e.g. entire, east wing, room N. (e.g. Pipe lagging, ceiling, plenum FEET FEET removing and replacing boilers. etc.) boiler room, lobby, etc) ducts. storage tanks, decking, etc.)

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knowledge. I am familiar with Federal, 31. I hereby declare that the information provided herein is true and complete to the best of my State and NYC laws and reaulations applicable to asbestos related work.

odor Print Na a of A stns tractor Print Name of Applicant (If other than Owner) Prin ame of Av

Signature Signature Signature

--WcI_ -------------------- Date Date Date

am responsible for the performance of 32. I understand that as the owner of a building where asbestos abatement activity occurs, I 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 asbe tos project. I hereby declare that I have authorized the herein. filing of this notification for the work specified _ Signature - pa' c 1o31a~Date Print Name of Owner THE WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT writing directly to the NYC DEP ACP. I Any modification of information provided on this form must be reported immediately in or lessened The requirements of the Asbestos Control Program Rules may not be lawfully avoided through the performance of work in incremental or piecemeal fashion. ACPr 10001

NYC-WTC 000111294