Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler LO 0 NYS DEC O Tel. -2 72 3 7 Disposal Site(s)_COI ekNUj~~QWje_5"ermiJ, ((7' / •i

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) 0 Sprinkler Replacement d) ❑ Renovation/Aferation e) ❑ Fireproofing Replacement t) ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation 0 Repair ❑ Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ FuII 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 (e.g entire. east wing. room •. (e.g. Pipe ta99irq. oaang, plen,m SQUARE L/4EAR p.0 n,r,n;ng dble, installaq rre sprinktent boiler room. . etc FEET removi and r tP .c ducts, tanks. deck' . etc. FEET '

r3I' bolters. 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.

Print ~tratat~.ft_ itor /v Prin Name 1c7 Contractor ~l Print Na. 7 of App ant (K other than Owner) C t nature

~~S03 Date Oet. ()ate

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 filing of this notification for the work specified herein.

Print Nem. of Owner Signature t. 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 Iessened ] through the performance of work in incremental or piecemeal fashion. I AM le=1

NYC-WTC 000111323