Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

6. Asbestos Hauler IESI.NY _ NYS DEC Permit # NJ-462 _ Tel.# (718) 522.2263

Disposal Site(s) BlueRidge Landfill PO'Box 399 Scotsdale, Pa 17254

27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) O Demolition b) O Boiler Replacement c) O Sprinkler Replacement d) O Renovation/Atteration e) O Fireproofing Replacement f) El Other (Describe)

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

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

nn t nrATtnuc nc A ATC a IJT Pmt= M d•TC1Lt er • Drnc &A st*J Qa& CTA& DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR I CONTAINING ACM PERFORMED SQUARE LINEAR to g running cable. installing fire spnnklers, • leg entire east wing, room a le g Pipe lagging. ceiling, plenum boiler room, lobby etc) FEET FEET I removing and repiaong boilers etc suct5 storage tanks decking etc

ROOF Vr~ot= soeF 105 P eAt€r WAu. 4OT SET BAOL Bc't4u~ RooF RcoF uQFi~CE '*-q/c 1 500 aN 4-Acwo~ ; li c: fe ac ( NnssAu S-A 142S I a.eoF RL30c ►1~A, D 200 Faco.oe I : AwutNG, iocn ioE ) zoo

H - - H --- ' ________ I I I

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31. 1 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.

Print Narfte of Air Monitor Print Na of As stos Contractor Print Name of Applicant (It other than Owner)

nature --- gn ure Signature ---------

Date --- - ----- Date ---- I Date

32 I understand that as the owner of a building where asbestos abatement activity occurs. I am responsible for the performance of the asbestos abatement activities in accordance with the Asbestos Control Program Rules. I have contracted the third party air 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. _ _ ocil3102. Print Name of Owner Signature Date

A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.

I Any modification of information provided on this form must be reported immediately in writing directly to the NYC DEP ACP. The requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened through the performance of work in incremental or piecemeal fashion. ACP? L200t

NYC-WTC 000111280