Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler —JESt, N!?-- r NYS DEC Permit # W -462 Tel.# Czs 22 - 2263_

Disposal Site(s) Sla3e (zt D6E tAuo t=ILL Po e ox SCoTSD,4r a= Psa tt 2 SQ •<.-:-• ` :___

27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) ❑ Demolition b) ❑ Boiler Replacement c) 0 Sprinkler Replacement d) ❑ Renovation/Alteratipn,, e) ❑ Fireproofing Replacement f) ❑ Other (Describe) ._ _— _-

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

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

J1 I ACATIANS flF ARATFMFNT PrY\F MAT€2-tAL . QLOf MEM$R&ISE (TAB DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room p, (e.g. Pipe lagging, ceiling, plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers, boiler room, lobb , etc) ducts, stora a tanks, decicin , etc.) FEET ' FEET removing and re lacin boilers, etc.

ROOF 1l2cOF Su2F,&c . 382..E.

Ducc5 2.880

METAL. Suc.F,cES IOGO

~O UIJ __ 2500 Cc.1cC 5 c—tl~S6 ~~ lvotzstl Ca sueF,•caC 60_ ~3 ~ws^arw s . s~ 3a.cr

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.

WARIt_E1J I PANzER t 6iNEEPZ B. Kv N _ to tJ CGf3iVOL _ Print Name of Air Monitor Pa Na a of I ' be Contractor Print Name of Applicant (if other than Owner)

Signature Signature Signature

O8-2T-02 -- O8-2r-02. _ 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 asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein.

Print Name of Owner Signature Date

A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. V. 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. ACPr 212001

NYC-WTC 000111321