Asbestos Project Notification form, Oct 2001

NYC 9111 Public Portal Document

.ASBESTOS INSPECTION REPORT (continued) NYS DEC Pemiit# CT-098 Tel.# 800-272-3867 ?s_AsbestosHauler li'ocfano Southern Alleghenies Valley Landfill Disposal Sites) Department of Buildings) (Item a through e requires filing of this form with NYC 27 This asbestos abatement is part of a d) ❑ Renovation/Alteration b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement a) ❑ Demolition (Describe) e) ❑ Fireproofing Replacement t) 0 Other appropriate boxes) 28. TYPE OF ABATEMENT (Check all ❑ Clean up ❑ Removal ❑Enclosure ❑ EncaPsulation 0 Repair appropriate boxes) 29. ABATEMENT PROCEDURE (Check all ❑ Glovebag ❑ Tent ❑ DEP Variance Application ❑ Full Containment

am familiar with Federal. herein is true and complete to the best of my knowledge. I 31. I hereby declare that the information provided asbestos related work. State and NYC laws and regulations applicable to

Fiber Control, Inc. Fiber Control, Inc. A.T.C. Associates of Applicant (if other than Owner) Pritrt/lerneof Air Monitor Print Name of Asbestos Contractor

Signs e ignature

responsible for the performance of where asbestos abatement activity occurs. I am 32. I understand that as the owner of a building Asbestos Control Program Rules. I have contracted the third party air accordance with the the asbestos abatement activities in involved in the asbestos project. I hereby declare that I have authorized the monitor who is completely independent of all parties herein. filing of this notification for the work specified As per cleaning request form Date Print Name of Owner Signature SITE. AMENDMENTS MUST BE AVAILABLE AT THE WORK A STAMPED COPY OF THIS FORM INCLUDING the NYC DEP ACP. this form must be reported immediately in writing directly to [Anv modification of information provided on Program Rules may not be lawfully avoided or lessened The requirements of the Asbestos Control piecemeal fashion. through the performance of work in incremental or 212~001

NYC-WTC 000111317