Asbestos Project Amendment form, Oct 2001

NYC 9/11 Public Portal Document 1

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler NYS DEC Disposal Site(s) eAJie5'""Muff 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) ❑ Sprinkler Replacement d) ❑ RenovatioNAlteration e) ❑ Fireproofing Replacement f) ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair 0 Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent 0 DEP Variance Application 30. LOCATIONS OF ARATFIAFUT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM (a 9 entire, east wing. room H. (e.g. Pipe a99irv. ailing. plenum SQUARE LINEAR (e.g PERFORMED baler to mm~irp able, iruwr fn . etc ducts. st tanks. . etc.) FEET ' FEET cktus. removi and re tea al )

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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.

sort c~ at.. A4 t 57 ,y Pant N r ilor Pnn Name toe Contractor Pnn; Nan of App ( nt If other than Owner)

Signature rye Signaturo oCr,- o3--oil -3-02 Date Data 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 monitor who is completely independent of all parties involved in the Program Rules. I have contracted the third party air asbestos project. I hereby declare that I have authorized the cati t the work cified herein. Ayl;~ d er _______

t nstte 1'°° it A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE [.Arty modification of information provided on this form must be reported immediately in writing directly to the NYC DEP ACP. of the not be lawfully avoided or

NYC-WTC 000111339