Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) :

26. Asbestos Hauler tESt, ►.1Y NYS DEC Permit # u~ -4 b2 Tel.#__;

f3Lu 4CI E LMAoct L PO 0a( l3" 5 -r s * *A " 4 Disposal Site(s)

27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) '1 .

'a) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement f) ❑ Other (Describe) —

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag 0 Tent ❑ DEP Variance Application nA 1 A/'AT1^&1Q AO AOA W&l k1T •/~' X O / / / C) /~' //J/ _ f 0

DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SQUARE UNEAR (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 toilers, etc.)

FP.CA0E Q€ ;ESCAPES ?So

____ So- t 1 z 3430

Qom 2cc* 5R° 34T9 n p~,p~.r 333

It t tc 1E .D 5013

" At M>~TAz 43O - (00

sir Brtctt f2~o F ttcoP Sv¢FACE ?35 it tryC UN ►TS 4000

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

tfa Yc '~-..r 'i k or2 o a v-d So Print Name of Air Monitor Print me of Asbestos Contractor Print Name of Applicant (If other than Owner)

r. Signature Signature Signature

19 / 7/ Date Dte Date

performance of 32. I understand that as the owner of a building where asbestos abatement activity occurs. I am responsible for the third party air the asbestos abatement activities in accordance with the Asbestos Control Program Rules. I have contracted the authorized the monitor who is completely independent of all parties involved in the asbestos project. I hereby declare that I have filing of this notification for the work specified herein.

Signature Dale N Print Name of Owner THE WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT directly to the NYC DEP ACP. Any modification of information provided on this form must be reported immediately in writing of the Asbestos not be lawfully avoided or lessened ACP? ?!2001

NYC-WTC 000111296