Asbestos Project Notification form, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) .. 26. Asbestos Hauler Lo J~ NYS DEC Permit —6 Tel. ~$Qt> X72 3 <S 7 Disposal Sites) O ( (1€&P fE ~1QN •e 5 14' ! 'l 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) ❑ RenovationfAfteration e) ❑ Fireproofing Replacement 0 ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) A ❑ 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) J OF FLOOR (e.g satire, eau wing. mom I. CONTAINING ACM (e.g. Pipe lagging. aiiftg. Plenum SQUARE t NEAR PERFORMED (e.g nuning cable. Ytwffing fre sprinklers. boner room. bby. etc) ducts. storagetanks, deø.i . etc.) FEET • FEET ram rig and rpt.dng balers, atc.)

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

P.vr for tune Contractor Pnnt Na . or App nt (M finer than Owner)

Srpnattue nature Signature

Date Mete pate

32. t 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 is notification for the work specified herein.

Pant Name of Owner &grtattra Out

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. I Acer Sacco+

NYC-WTC 000111307