Asbestos Project Notification form, Oct 2001

NYC 9/11 Public Portal Document

~11.__. ASBESTOS INSPECTION REPORT (continued) Asbestos '26. Asbestos Hauler Transportation Co. ' NYS DEC Permit# 1A-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) 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 ❑ Enclosure ❑ Encapsulation ❑ Repair ❑ Clean up

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

30. LOCATIONS OF ABATEMENT `(' ~~ ¼i ', 11 t ,, DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEfr1G 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.) 5th Item No. 2 Courtyard Roof 1330 12th Item No. 2 Setback Roof 750 17th Item No. 2 Setback Roof 1450 Facadi Item

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

Warren & Panzer Trio Asbestos Rvl.Crp. NYC Print Name of Air Monitor P ' NamspI St Contractor Print Name of Applicant (If other than Owner)

/i / Signature Signature Signature

________________ /iq/ ________________

Date 4 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. 50 Broadway Realty Corp. c/o t o~- Print Name of Owner Signature T- Date

A ST2MPEU7CUPY OF THS FORMINCLUDING 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. a The requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened ACP7 through the performance of work in incremental or piecemeal fashion. 22001 J

NYC-WTC 000111462