Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued);

26. Asbestos Hauler tEst, ►3Y NYS DEC Permit # Tel.# _J'e`t

LA.AOc%LL P0 a( 139V 5cscsr s i , -te Af ' Disposal Sitg(s) C31s o-- E

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) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration

e) ❑ Fireproofing Replacement f) ❑ Other (Describe) -

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment O Glovebag O Tent ❑ DEP Variance Application /O/ f ,in It t t"ATInuC nC ARATC&ACAIT '1 ' O t' 0 DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION O 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 FEET removing and replacing boilers, etc.) boiler room, lobby, etc) ducts, storage tanks, decking, etc.)

FACADE f-E zSCAPES ?So F Ac . St ,VMk e 3430

Rc Rcc* 3479 n .per , 333

K gctt~c Ea.D 500

r• T fit.. wO*- (OO gET cY ttooP SQP-r-ACA-= ?35 it . _ ufJ ►TS 4OOO

Federal, 31. I hereby declare that the information provided herein is true and complete to the best of my knowledge. I am familiar with State and NyC laws and regulations apQlicable to asbestos related work. - A W.4 fl Z

Print Name of Air Monitor Print me of Asbestos Contractor Print Name of Applicant (If other than Owner)

r. Signature Signature Signature 1 a . ►9- Z. / 7/ Date Date Dte

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

Signature Date N Print Name of Owner THE WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT formmustbereportedimmediatelyinwritingdirectly to the NYC DEP ACP. An modification of information rovided on this or iesseneu The requirements of the Asbestos Control Program Rules may not be lawfully avolaea ACP7 V2001

NYC-WTC 000111296