Asbestos Project Notification form, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) -~ Asbestos 26. Asbestos Hauler Transportation Co NYS DEC Permit# 1 A-371 TEL.# 631-924-5050 DisposalSite(s) Imperial/POB 47, 11 Boggs Rd., PA: Southern Alleghenies Valleyview Dr., PA 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) 0 Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement 0 ❑ 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 ❑ Tent ❑ DEP Variance Application

30. LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM t1ii/ccq/ j1Qo DESCRIPTION OF WORK BEING Floor(s) OF FLOOR . CONTAINING ACM PERFORMED (e.g. entire, east wing, room it, (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 boilers, etc.)

OOFS Item No. 3 Partial Roofs 13560 Facades Item No. 8 Partial Facades 45500

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.

Warren & Panzer Trio Asbestos Rvl.Crp. N Print Nam~Airr Pd Name Ef Asb Conlrador P Na of p f ether than caner)

_____ _____ 1 i

Sgnatute Signature Signatu

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. c/o NYC 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 Asbestos Control Program Rules may not be lawfully avoided or ACP7 h the performance of work in incremental or Diecemeal fashion. 2/2001

NYC-WTC 000111375