Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

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ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler (_o' /f4tJO NYS DEC Permit -272-3~ k Disposal Site(s) Gov 11? e2 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) ❑ Boiler Replacement c) 0 Sprinkler Replacement - d) ❑ Renovation/Alteration e) 0 Fireproofing Replacement I) ❑ Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full 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 S. (e.g. Pipe lagging. cuing. plenum SQUARE LINEAR (e.g. n.mnutg able. installing fire sprinklers, boiler room. lobby. etc) ducts, storage tanks, dedtifle. etc.) FEET ' FEET removing and replacing boilers. etc.)

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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.

I S~ ctMr.tA4t4 _ CJ7J .)7 J}r P..nt N itor Prin Name f Asbestos Contractor Print Nara of App nt (If other than Owner)

Signature nature 4iSignature

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32. • I understand that as the owner of a building where asbestos abatement activity occurs. I am responsible for the performance of .theasbestos 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 f this Ywti~Fa ' for the work specified herein.

Pnnt Named r Signature Date

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

Any'nodiflcatiort 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. I AcPM yloot

NYC-WTC 000111333