Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler LOC3 /ti"' o

NYS DEC Permit

Disposal Site(s) .eiJle 5 . ►G 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)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal 0 Enclosure 0 Encapsulation 0 Repair 0 Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 Glovebag ❑ Tent 0 DEP Variance Application -2n 1 n(`ATIANC AC ARATCtAt=NT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SQUARE LINEAR (e.g. running cable, installing fire sprinklers, (e.g. entire, east wing. room p, (e.g. Pipe lagging, ceiling, plenum FEET FEET removing and replacing boilers, etc.) boiler room, lobby, etc) ducts, storage tanks, decking, etc.)

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.

Print N rr itor Prin Name f AS stns Contractor Print Nam of App .ant (If other than Owner)

Signature gnature Signature

Date Date Date

I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the performance of 32. 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 Qf this no ification for the work specified herein. —

Signature Date Print Name of Owner

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

Any modification of information provided on this form must be reported immediately in writing directly to the NYC DEP ACP.

of the Asbestos Control Program Rules may not be lawfully avolaea or ACP7 2=01

NYC-WTC 000111401