Asbestos Project Notification form, Nassau Street

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) !`att__~ 26. Asbestos Hauler . JSI 1 _ N4 ____~ NYS DEC Permit #- t1I - 462 __ Tel.# CZ16) S22- 2263

DisposalSite(s) wERIOGE LANDFILL- PD Box 399 N SCor---0A%t= PA I"t254 --

27 This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) 0 Demolition b) 0 Boiler Replacement c) 0 Sprinkler Replacement d) 0 Renovation/Alteration e) 0 Fireproofing Replacement f) 0 Other (Describe) _ N —___--_------_

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag 0 Tent ❑ DEP Variance Application

In I ACATIANS 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, FEET FEET removing and replacing boiler, etc.) boiler room, lobby, etc) ducts. storage tanks, decking. etc.)

R ooF Roos S:>cFs>,c:E S G 14

t=ae's ve t~s Fpc A0E Q~W N I IJ G S 100

FAC&t &iflhI •t t ACA PE S E OOO

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.

(V~E+~►J ~( ANZ&iZ ~1tC-rt►rc~~kS ?_KUL'ZBAi t'u _ r t Name of Air Monitor Print Nam Asbesto onl for Print Name of Applicant (If other than Owner)

Signature Signature Signature

_ __ O9-cs-c2 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 completely independent of all parties involved in the asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein. t fC:OEP c9os102— Signature Date Print Name of Owner

WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE the NYC DEP ACP. An modification of information rovided on this form must be re orted immediate) in writin direct) to lessenea rements of the Asbestos Control Program Rules may not be lawfully avoided or through the performance of work in incremental or piecemeal fashion. ACP7 212001

NYC-WTC 000111365