Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document (22 %JASSAru SrT ASBESTOS INSPECTION REPORT (continued)

Asbestos Hauler IESI,NY NYS DEC Permit # NJ462 Tel.# (718) 522-2263

• Disposal Sites) BlueRidge Landfill PO Box 399 Scotsdale, Pa 17254

27. This asbestos abatement is part of a (Item a through a requires filing of this form with NYC Department of Buildings) a) 0 Demolition b) 0 Boiler Replacement c) 0 Sprinkler Replacement d) 0 Renovation/Alteration

e) 0 Fireproofing Replacement f) 0 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) ❑ Full Containment 0 Glovebag ❑ Tent 0 DEP Variance Application

30 LOCATIONS OF ABATEMENT Q.00t~ µATU-i = ROOF Me4 ISR.a JG (TA1 0 DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) I OF FLOOR CONTAINING ACM PERFORMED SQUARE LINEAR leg running pole, mstang w fire sprinklers. leg entire east wing, room n le g Pipe lagging, ceiling, plenum FEET FEET Oder room iobb SIC) ducts storage tanks decking.etc removing and replactrig boilers etc

ROOF ¢FACE W ooc6 r 25 'SET K 25 QOOF $u , E. ~uurr' I i I

I I ~

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.

I

Print Name of Air Monitor Print Nam Contractor Print Name of Applicant (it other than Owner)

Signature Signature

--61 oL --- - I —---- 32 1 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. _ d J13 IO2 Print Name of Owner Sgnature Date

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

[ Pnv 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? V2001

NYC-WTC 000111284