Asbestos Project Notification form, Oct 2001

NYC 9/11 Public Portal Document

1

ASBESTOS INSPECTION REPORT (continued) Co _ 26. Asbestos Hauler _ NYS DEC permit Tel.l~ $~ X72- 3 7 Disposal Site(s)

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) 0 Boiler Replacement c) 0 Sprinkler Replacement - d) 0 Renovation/Alteration e) ❑ Fireproofing Replacement t) 0 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 FLOOR CONTAINING ACM PERFORMED (.9 entire. east wing. room I. (e.9. Pipe bggino. oeaing, pienum SOUARE LINEAR (e.g rji. able. wtsWling fre sprinkisim boiler room. lobby. etc) ts. st )Qe tanks. deck' . etc. FEET"_- FEET rsmovin and acn toilers. eta)

Vcc -1 (AsU-) __________

31. 1 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.

js cl rs c[ at at kf 2 57 23Th~'~ Print N itor Pnn Name Asbestos Contractor Print Na . of App nt (If other than Owner)

Signature nature Spnature

Date - —c Date Data

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 fil' of th4notih on for the work specified herein.

P wner _ Signet " a A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE

An modification of information rovided on thisformmustbereportedimmediately inwritingdirectly to the NYC DEP ACP. requirements of the Asbestos Control Program Rules may not be lawfully avoided or through the performance of work in incremental or piecemeal fashion. ACPI xmo+

NYC-WTC 000111305