Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler NYS DEC Permit CT O~ Tel. $~ "Z72' .3 ~,1? ~~~ Disposal Site(s) _ U e2N tr//E? S Ji 5j 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 0 Glovebag ❑ Tent ❑ DEP Variance Application

,An LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SQUARE LINEAR (e.g. runnirig cable, installing fire sPnnklers, (e.g. entire, east win9. room ri, (e.g. PiPe lagging. ceilinG. Plenum FEET ' FEET removing and replacing boilers, etc.) boiler room, lobby, etc ducts. storage tanks, dedti , etc.)

-LL. ~-1 b

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.

Pnnt N 1r dor Prin Name f Asbestos Contractor Print Nam of App ant (If other than Owner)

r Signature gnature Signature

_ ~~- 0:0 . 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 th• notification for the work specified herein.

Print Name of Owner Signature Date

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. The requirements of the Asbestos or lessened ACP7 2 oot

NYC-WTC 000111425