Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document 120 I1ASSM) sTRIIEET ASBESTOS INSPECTION REPORT (contlnued) NYS DEC Permit # NJ-462 Tel.# (718) 522-2263 6. Asbestos Hauler IESI.NY

A Disposal Site(s) BlueRidge Landfill PO Box 399 Sootsdale, 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) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration

e) O Fireproofing Replacement f) El Other (Describe)

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

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

. I IV`ATr(uQ nC AInATcIJ IJT e.,..c All A-v .1 a1 - QirtrF LEmi5eAms CT re_ )

DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR (e g entire. east wing room a II (e g CONTAINING ACM pipe lagging. ceiling. plenum SQUARE LINEAR PERFORMED to g running cable. installing fire spnnkiers. FEET FEET removing and repiaong boilers etc boiler room looy etc) ducts storage tanks decking etc t

ROc* QcoE Su¢FACE 12 3 ►~ PAe*Mr W an,,L ! 443 n Mrt wotuc 30 oN G-^Ar1L i r,t~r nwt (Ne.s tna 1, %425 I

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31. I 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 Name of Au Monitor I not N me of Print Name of Applicant (if other than Owner)

igna" Signature

— 3 --- - ------ 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. DEP OG. I f 3'OZ Print Name of Owner Signature Date

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

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? Vrloot

NYC-WTC 000111282