Asbestos Project Notification form, Nassau Street

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) I ESI , NY NYS DEC Permit # (4i- 462 Tel.# C -us)S22 2203 26. Asbestos Hauler BOY- 399 SCOTSDAt PA t•T254 Disposal Site(s) but e+D4E LAwoFt uL 'P0 Department of Buildings) 27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration a) ❑ Demolition e) ❑ Fireproofing Replacement f) 0 Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) 0 DEP Variance Application / ❑ Full Containment 0 Glovebag 0 Tent 33 ✓ r n-r- a rCOSA. _ Q. I iABa.AttE. • ` 0 1, b' ` AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING DESCRIBE SECTION CONTAINING ACM PERFORMED Floor(s) OF FLOOR SOUARE UNEAR (e.g. running cable, installing fire sprinklers, (e.g entire, east wing, room M. (e.g. Pipe lagging. Ceiling, plenum FEET ducts, storage tanks, decking. etc.) FEET ' removing and replacing boilers. etc.) boiler room, lobby, etc)

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

uuaaem I PAstz E aGtees 'B . k-ut2t-eAN 4 Scy Cwrre,ot.. Print Name of Al nitor Print ame of Asbestos tractor Print Name of Applicant (if other than Owner) It

t. . Signature Signature gnature _ r og_t9-02 o8 -t9 -o2 Date Date Date

responsible for the performance of 32.•+1 understand that as the owner of a building where asbestos abatement activity occurs, I am "the asbestos abatement activities in accordance with the Asbestos Control Program Rules. I have contracted the third party air as tos project. I hereby declare that I have authorized the monitor who is completely independent of all parties involved in i tiling of thisnotification for the work specified herein. 1

Signature Date • Print Name of Owner AT THE WORK SITE. i - ( `A'STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE directly to the NYC DEP ACP. liii An modification of information provided on this form must be reported immediately in wntinq lawfully avoided or lessened - The requirements of the Asbestos Control Program Rules may not be work in incremental or piecemeal fashion. through the performance of 2r200t

NYC-WTC 000111367