Asbestos Project Notification form, Nassau Street

NYC 9/11 Public Portal Document

SBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler I E51 N'L—__—__ NYS DEC Permit # ul - 4 62 —_ Tel.# - C't t t3) S22-22 3

Disposal Site(s) PSLu ~pGE L oFtu PO Box 399 SCo1StDRtg PA 11254'_--

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) ❑ Other (Describe) _—_______--_—N~_—__---------

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 Glovebag 0 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 SQUARE LINEAR (e.g. running cable, installing fire sprinklers, (e.g. entire, east wing, room #, (e.g. Pipe lagging, ceiling, plenum FEET ' FEET removing and replacing boilers. etc.) boiler room, lobby, etc) ducts, storage tanks, decking, etc.)

ROOF ROOF Sc; CE 2522 SET R~COF S;24 ACE '128 it Alc 4 M fi t_ 1000

FACe.p€ Ea3r FcA C) 2CSQ u ( Wes;. F^CAve tec,r~or. S11e.ene-rG 2340

Ftl2C— 2100

Federal, 31. I hereby declare that the information provided herein is true and complete to the best of my knowledge. I am familiar with State and NYC laws and regulations applicable to asbestos related work.

WA2Qs is I i4 z B. Ku zS tJ j So►! CC►1=-L _ Print Name of Air Monitor Pa I ame of s stos Contractor Print Name of Applicant (If other than Owner)

Signa ure Signature Signature(G

c`9.-05 -c 2 09 —c5.-c2 --__ Date Date Date

performance of 32. I understand that as the owner of a building where asbestos abatement activity occurs. I am responsible for the contracted the third party air the asbestos abatement activities in accordance with the Asbestos Control Program Rules. I have have authorized the monitor who is completely independent of all parties involved in the asbestos project. I hereby declare that I filing of this notification for the work specified herein. - ~ ~ I+yc`f)cP t~9 ~ o ~c2 Signature Date Print Name of Owner THE WORK SITE. j A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT the NYC DEP ACP. 1 Any modification of information provided on this form must be reported immediately in writing directly to iessenea rements of the Asbestos Control Program Rules may not be lawfully avoidea or through the performance of work in incremental or piecemeal fashion. 2/2001

NYC-WTC 000111355