Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler I ES t , N`~ NYS DEC Permit # 1' - 462 _- Tel.# _Cz t t;) S2'2-223

Disposal Site(s) I.WtDFtIJ_ PG Box 399 S T iT254

27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) '. s~ a) 0 Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) 0 Renovation/Alteration e) ❑ Fireproofing Replacement t) ❑ Other (Describe) N—_ _— _---__—_ —__

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

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

3A. LOCATIONS OF ABATEMENT rLCOP GvtATEQ L . t2CDt` MEM(32i~NE (TAR" ) i1 I' - DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SQUARE LINEAR (e.g. running cable, installing fire P sprinklers. (e.9• entire, east wing, room p, (e.g. Pipe 99 n9• plenum n9• ceiling, tagging, boiler room, lobby, etc) ducts, storage tanks, decking. etc. FEET FEET removing and replacing boilers, etc.)

(200F ROOF Sutzt=n.CE t l25

tt ME St )ILFAf= S 200 SeT eac ___ 2~GF 'c/.>`E E500

u ABC uN crS A t OCM i T o0 fACr. € U-ES t'Pcs Di 1500

N E713T FP.C.o•c€ Fpc o pe Sc c_4 Ac E I S-(5 it It ST(J t f ZMT /A'S'.tl 'S 500

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.

UJARQEN 1 PAN T-4em ENG l _JEEt25 B• flu 2 e Aw 4 S N Cota7ttot I NC Print Name of Air Monitor d Name of Asfros Contractor Print Name of Applicant (If other than Owner) \\, Sign lure - Signature

OS -2T -o2 _ Date Date 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 a bestos project. I hereby declare that I have authorized the •filing of this notification for the work specified herein. i t~ N1C DEt t -2 t -O 2 Print Name of Owner Signature Oate

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. 2/2001

NYC-WTC 000111319