Asbestos Project Amendment form, Oct 2001

NYC 9/11 Public Portal Document 1

ASBESTOS INSPECTION RI (continued) 26. Asbestos Hauler Co NYS DEC ^ermit Disposal Site(s)

27. This asbestos abatement is part of a (Item a through a requires filing of this form wIN NYC Department of Buildings) a) ❑ Demolition b) ❑ Boiler Replacement c) 0 Sprinkler Replacement d) ❑ Renovation/Afteration e) ❑ Fireproofing Replacement fj ❑ 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 entire. east wing. mom t. (e.g. Ptpe tagging• eeling. plentrrrt SQUARE LINEAR (e.g nxwinp cable. inatafling fn Sprinklers. boiler morn. lobby. etc) ducts. staetanks. . etC.) FEET FEET n*1flOflflQ and S1OflQ boilers, etc

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.

Pvx N itor Pnn Name tos Ctxeactor Pnnt Nam of App cat (M other than Owner)

Signature natum Signature

Date Oete Date

32. 1 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 ti of this notifi i for th work specified herein. a i.A. Dr Pnrt Name owner Sipne4xe to

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

[lAity 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. I Acv? awl

NYC-WTC 000111341