Asbestos Project Notification form, Nassau Street

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler IES i , NY _ __ NYS DEC Permit # jJ- 462 __ Tel.# (,tls) 522 - 2263

Disposal Sites) t3iuE ttto LnaoFlr L P0 box 399 Sco Qg1E PA 17254

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) __

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

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

30. LOCATIONS OF ABATEMENT ROOF l-4A Q4AL. : QA ee R. 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, deding, etc.) FEET FEET removing and replacing boilers, etc.) TOP ROOF RotoF ~; 2A96 MIOOI,E r.00F F sa c..€ 884 IAI.ItJ ROOF ROOF s.:t.Fn. T634

%I114 Ft SET IBACIG RF Suec~.c (68 11 a METI.L SJCFAC-ES 50

5T11 Ga_ &rIEET S10 (OIN 4 LEDGES 60 2- uW10DOWS

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.

cu saae).t 4 Pi z.e . Enw .,,M-ZS T. " SAta $ fr / Print Name of A' nitor ri t Name of tos Con for Print Name of Applicant (If other than Owner)

gnature Sig t e Sgnature

IS - 02. 08-tS- o2 _~ 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. _ 08-15-02.. Print Name of Owner Signature Date

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

I Any 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. ACPi 212001

NYC-WTC 000111369