Asbestos Project Notification Form, DEP Box 39

NYC 9111 Public Portal Document 124 4AS&AU STET ASBESTOS INSPECTION REPORT (continued)

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

Disposal Sites) 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) ❑ Fireproofing Replacement f) El Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) 0 Removal 0 Enclosure 0 Encapsulation 0 Repair Clean up T` 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag 0 Tent 0 DEP Vanance Application

30 LOCATIONS OF ABATEMENT QooF Rec c ItAEMeRI'+rE (TAP- DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED RE 1e g running caoie. installing fire spnnklers. (e g entire east wing room a (e g Pipe tagging. ceding, plenum LINEAR I etc FEET FEET removing and repiaong boilers etc) Doder room. 000v etc) ducts. Storage tanks decxun

serBodc l 2 S Qao F 1 : Roof Soar-okaE. SETBA 2 1k0F lolpAL'~ 4'2S Roca M WC -,K 300 I 6.Ra:ua 'Bact~~aao sn►t -s 1000 pN i (uws r ) 1.2co :fu T FACI►OE u ~t¢E tic kyv 150 --- ~-- — -- F~co.oar ' t tN(t (otxstaE) 120 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.

Prot Name of Air onitor Print Name of AsbeStps Contractor Print Name o' Applicant (11 other than Owner)

S.gnature

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. _ ptrf~ O6 113'OZ Print Name of Owner pnature 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? 2000+

NYC-WTC 000111286