Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document I Z2 NA,s.A4 s- -r ASBESTOS INSPECTION REPORT (continued)

6. Asbestos Hauler IESI,NY NYS DEC Permit # NJ462 Tel.# (718) 5222263 17254 • Disposal Site(s) BlueRidge Landfill PO Box 399 Scotsdale, Pa

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

e) O Fireproofing Replacement f) 0 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

30. LOCATIONS OF ABATEMENT 2cOt= µATU-i = ROOF MErtB evsiG CTPrR-) DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SQUARE LINEAR leg running pole, installing fire spnnkiers. • leg snore east wing, room a le 9 Pipe tagging, ceiling, plenum FEET FEET coder room boDy etc duct storage tanks decking etc duc removing and replaorig boilers etc

ROOF ¢FAC-E (L ' r) 25 s R enCW i i Qr r t= SuQ ~rE I r usa rr ) 2S 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 __Sd!V I Contractor -- -------- Print Name of Applicant lit other than Owner) Print Name of Air Monitor Print I

I Signature Signature ^n I

—__~ Oats --- ------

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 113102 Pnnt 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'1 moot

NYC-WTC 000111284