Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

. t ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler LO9i JO NYS DEC Permit Disposal Site(s) 27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) 0 Demolition b) 0 Boiler Replacement c) 0 Sprinkler Replacement d) 0 Renovation/Alteration e) 0 Fireproofing Replacement f) 0 Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair ❑ Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 Glovebag ❑ Tent 0 DEP Variance Application 30. LOCATIONS OF ABATEMENT -Z€ /4'9b k~rOZ DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. enure, east wing. room S. (e.g. Pipe lagging. ceiling. plenum SQUARE LINEAR (e.g running cable. installi We Ogler bbb .elk ducts. st tanks. Deck' ,etc. FEET • FEET nsmovi arid ro lad boilers, gy etc.) m' 110 . A SD 0 3~

I 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 laws and regulations applicable to asbestos related work.

Pnnt N itor Prin Name stos Contractor Print Narn of App ant (if other than Owner) p l y~o _ Signature naluro Signature

Oate note pate

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

I ng f this notif tion f e work peed herei ica Print Name of r Signature W

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

LAny 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.

NYC-WTC 000111325