Asbestos Project Notification form, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT(continued) 26. Asbestos Hauler LO g /f )C NYS DEC ^erm Disposal Site(s) 1•eNie5 , Uffffey r 27. This asbestos abatement is part of a (Item a through a requires filing of this form with NYC Department of Buildings) a) ❑ Demolition b) ❑ Boiler Replacement C) ❑ Sprinkler Replacement d) ❑ Renovation/Afteration e) ❑ Fireproofing Replacement f) ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair ❑ Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application 30. LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOFA CONTAINING ACM PERFORMED (.9 entire, east wing. room S. (e.g. Pipe laggirp. aline, pkrvn SQUARE LINEAR (e.9 rt rvsirs9 nDk, tnstallinp (vs tiprinklers poser room, lobby. etc) duos. storagetanks . dedtir . etc.) FEET ' FEET renswi arsd replaong boilers. etc

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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 State and NYC laws and regulations applicable to asbestos related work. with Federal.

Pam N hor Name Contractor Pant Na of App ant (if other than Owner)

Spnature rot re Senators

Date ate 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. ________

T Pnnt Nerve d Owner taigrr4re / Oat l ° 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 NYCDEP ACP. requirements of the Asbestos Control Program Rules may not be lawfully avoided or #Pr

NYC-WTC 000111313