Asbestos Project Amendment form, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) ( ' 26. Asbestos Hauler S~DEC TO9 Tel. ~~ ~27Z'~36 ro Lam` / )~NYS Disposal Site(s) . OULekp (~ YI e,& ~e 5PermU(Lcy C .4 I" ,1

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) ❑ Sprinkler Replacement • d) ❑ Renovation/Alteration e) ❑ 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 ❑ 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. Pipe lagging, ceilin9• plenum SQUARE LINEAR 9 cable, installing fire P (e.g. cunning sprinklers, (e.9• entire, east win9• room ta:, boiler room, lobby, etc) ducts, storage tanks, decking. etc.) FEET ' FEET removing and replacing boilers, etc.)

?EDfpt S 8 7.5a _' I3

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.

Stl'rr_ Q CiFtl~fPrf i 51 we v d P"nt N _ r itor nn Name r Asb stns Contractor Prirt Nam of App nt (it other than Owner)

_ v Signature gnature Signature

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 completel independent of all parties involved in the asbestos project. I hereby declare that I have authorized the f ing f this notification f r the work ecified herein.

Date Print Name of er Signature

A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. to the NYC DEP ACP. L Any modification of information provided on this form must be reported immediately in writing directly The requirements of the Asbestos Control Program Rules may not be lawfully avoided or fesseneu through the performance of work in incremental or piecemeal fashion. Acvr 2a001

NYC-WTC 000111345