Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

120 NASSM) s -cEr ASBESTOS INSPECTION REPORT (contiinued)

6. Asbestos Hauler IESI.NY NYS DEC Permit # NJ-462 - Tel.# (718) 522-2263

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) 0 Boiler Replacement c) 0 Sprinkler Replacement d) ❑ Renovation/Alteration

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

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) 0 Full Containment 0 Glovebag 0 Tent 0 DEP Variance Application

3n LOCATIONS OF ABATEMENT Dr -W MA-r».t.: Poop k4t—cMF eAt.11= Ctre) DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR (e g enure. east wing room it II (e g Pipe lagging. ceiling, plenum CONTAINING ACM SQUARE LINEAR PERFORMED to g running cable. installing fire sprinklers. Dater room b oy etc) FEET FEET removing and repiaong boilers etc ducts storage tanks deciung etc t

Roa coE SuaFAce, 23 it WAS ! 443 II Mrt wotuc 30 dN »✓.., writ i Irlerr wnArlC Ne.s~n..t , %425 o Flue_ -P 2 bo ~ 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.

W~►~W — ~P CJ ~ _&Z1 _ Print Name of Art Monitor not N /f Print Name of Appl.cant (If other than Owner)

—-- S.gnature

32 Date --4 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. OG. I f 3'vZ 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. ACK 22001

NYC-WTC 000111282