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 # IJ1 — 462 Tel.# (1 i8) 522 -2 2 3

PO BOX 399 Sw r-soAuE L PA 17254 Disposal Site(s) BLtCL2GE LkuO Fl LL of Buildings) 27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration a) ❑ Demolition b) ❑ Boiler Replacement e) 0 Fireproofing Replacement f) 0 Other (Describe) ------- — --------------

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 Glovebag 0 Tent ❑ DEP Variance Application _ ■-.-...-.—~-__ _ o_..~ ~_ _ cao~U . 1Acu 3U.LUGAt1VrvJUr AOAlomranr Fa.ws AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING DESCRIBE SECTION PERFORMED Floor(s) OF FLOOR CONTAINING ACM LINEAR SQUARE (e.g. running cable, installing fire sprinklers, (e.g entire, east wing, room p, (e.g. Pipe lagging. ceiling, plenum FEET FEET removing and replacing toilers, 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 regulations applicable to asbestos related work.

IN2a,4t' i- sow ntAGame of Asbestos ntractor Print Name of Applicant (If other than Owner) Print Name of Air

i nature Signature Signature

occurs, I am responsible for the performance of 32. I understand that as the owner of a building where asbestos abatement activity 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 the in asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein. Date Print Name of Owner Signature

AVAILABLE AT THE WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE in writing directly to the NYC DEP ACP.IIj Any modification of information provided on this form must be reported immediately lawfully avoided or lessenea The requirements of the Asbestos Control Program Rules may not be ._ __ '------- _, ..,...nt f.chinn ACP7 ?ROOt

NYC-WTC 000111300