Asbestos Project Notification form, Nassau Street

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REP RT (continued)

26. Asbestos Hauler __ i E51z NL•. NYS DEC Permit # NI-4162 __ Tel.# ( -tt8)"s22- 22-c 3 _

Disposal Site(s) t3UllE t - Dr. E LAND Fi ut- P0 O i( 399 SCo_csv A `PA t72'S'4

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) 0 Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) 0 Fireproofing Replacement 0 ❑ Other (Describe)

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

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

a P-CcE Su -rye 18 75

DUCTS 4 A/c uu,r5 3000

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.

4 fANzGE EKX, t5 B • Ku 'ze.As.S So _ P'n e of Air Monitor Pri me of s estos Contractor Print Name of Applicant (If other than Owner)

^ ignature~

o.s'C12 Date _ _ Signature

•p9-05-C2 Date -~_

32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the performance of Signature

Date __

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 th asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein. 09 t O S 102 Print Name of Owner Signature Date

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

Any modification of information provided on this form must be reported immediately in writing directly to the NYC DEP ACP. II 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. ACP) 2/200,

NYC-WTC 000111361