Asbestos Project Notification form, Nassau Street

NYC 9/11 Public Portal Document

t AOSEIESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler __ I E512_11~-- ---___ NYS DEC Permit # Fib - A 62 Tel.# _ 522-

Disposal Site(s) Blue W I)6E LANDFIu PO BoX S99 — SCcTSORLE 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) 0 Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) 0 Renovation/Alteration

e) ❑ Fireproofing Replacement 1) 0 Other (Describe) _— ---- ------_--------

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

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

in LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. Pipe tagging, ceiling, plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers, (e g. entire, east wing, room #, FEET boiler room, lobby. etc) ducts, storage tanks, decking, etc.) FEET ' removing and replacing boilers, etc.)

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

l~ pQl:xu 4 PAN LGQ EN6ttvi x-125 -L Voo- 1W4 Sci4Cw;2c_ _ int Name of Air Monitor Pnn N me of A s Contractor Print Name of Applicant (If other than Owner)

Signatle Signatu Signature 9

C O9 -CS- 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 with the Asbestos Control Program Rules. I have contracted the third party air the asbestos abatement activities in accordance authorized the monitor who is completely independent of all parties involved in the as stos project. I hereby declare that I have filing of this notification for the work specified herein. __ NyCiJ~P %9 I U5 t C2 __ Signature Date Print Name of Owner WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE to the NYC DEP ACP. Any modification of information provided on this form must be reported immediately in writing directly or lessened requirements of the Asbestos Control Program Rules may not be lawfully avoided through the performance of work in incremental or piecemeal fashion. mot

NYC-WTC 000111351