Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

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ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler LO K44 L NYS DEC ^ermit —0 Tel gam ^ __ Disposal Site(s) le*J; S . \/1~-( Fi./ 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/Alteration e) ❑ Fireproofing Replacement f) ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation 0 Repair ❑ Clean up

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 Glovebag 0 Tent ❑ DEP Variance Application

30. LOCATIONS OF ABATEMENT

J DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g entire. east wing. coom s. (e.g. Pipe togging, coing. plenum SQUARE LNEAR (e.g. curving cable. installing fire winklers. baler soom. lobby, etc) tt, storagetanks. ded.ing. etc.) ET • FEET tlmovinQ and reptadriQ boilers. etc,

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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 taws and regulations applicable to asbestos related work.

b 15tuj Print MM itor ir Print Name Asbstos Contractor - ,vThd ( Print Na . of App r M (H other than Owner)

Spnatwe ntwrre Signature

oC )03- ~` Date ate ate 32. 1understand that as the owner of a building where asbestos abatement activity occurs. I em 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 li of this notificati or the work specified herein.

Print Name of r Sipneture at 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. Ater srzoo1

NYC-WTC 000111327