Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

6 i

ASBESTOS INSPECTION REPORT

26. Asbestos Hauler Co NYS DEC Permit gores —272-3& 7 Disposal Site(s) •2Nt25 , J* 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) 0 Renovation/Afteration e) ❑ Fireproofing Replacement n 0 Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application 30. LOCATIONS OF ARATFM iT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g entire. east wing. room i. (e.g. Pipe hggin➢, ceiling. plenum SQUARE LINEAR (e.g. ranting cable. installing fee sprinklers. bailer room, lobby, etc) ducts storagetanks, de g, etc.) FEET ' FEET removing and replacing toilers. 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 laws and regulations applicable to asbestos related work.

SU' uiliacleftc N( c u SI f~ ~cJl/~~xl~ ~5~ Print fl P ' Name As stns Contractor Print Nan of App ant (If other than Owner)

Signature nature Signature

Date Mete Date

32. ~erstlaratd~ttiat as the owner of a building where asbestos abatement activity occurs. I am responsible for the performance of asbestos ab*ment activities in accordance with the Asbestos Control Program Rules. I have contracted the third party air litor wkb is completely independent of all parties involved in the asbestos project. I hereby declare that I have authorized the ot'~1fis noti(ifati` for the rk spewed herein.

mp Owfer Signature Date

A CAMPED CbPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.

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NYC-WTC 000111331