Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler I ES I —NL — --_-- NYS DEC Permit # NJ — 462 TeI.# L1 i8) 522.2 2 3

PO 80X 399 SCeoTSPAt E PA 1-7254 Disposal Site(s) i2E,E LkOO Ft rLL of Buildings) 27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department b) ❑ Boiler Replacement c) 0 Sprinkler Replacement d) ❑ Renovation/Alteration a) ❑ Demolition e) 0 Fireproofing Replacement f) 0 Other (Describe) ------- -----------------

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 Glovebag 0 Tent 0 DEP Variance Application 0—.rc 1IAcM BQ.ANE SU. LVt..A I IVIYJ yr AO/11 ^ •

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

FACADE {:hSt %AC.&DE 680.4

FA~.AVE WEST Fp ADE Wtaoou: IO8O BULK EA ROOF Bc;t_K UL-ADS (IcoF 3T6

I' A/c UP ITS 200 wAus 4 ) PARAPET .eo r 354

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 regulations aoolicable to asbestos related work.

aR213,4Al d- s0R/ Print Name of Applicant (If other than Owner) Print Name of Air ntMame of Asbes os C.jntractor

i nawre Signature Signature

Date Date

I am responsible for the performance of 32. I understand that as the owner of a building where asbestos abatement activity occurs, Rules. I have contracted the third party air the asbestos abatement activities in accordance with the Asbestos Control Program involved in the asbestos project. I hereby declare that I have authorized the monitor who is completely independent of all parties filing of this notification for the work specified herein. 1s 10 Z 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.IiIIIJ Any modification of information provided on this form must be reported immediately lawfully avoided or lessened The requirements of the Asbestos Control Program Rules may not be fashion. i through the performance of work in incremental or piecemeal ~t

NYC-WTC 000111300