Asbestos Project Notification form, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler Asbestos Transportation Co. NYS DEC Permit # 1A-371 Tel.# (631) 924-5050

Disposal Site(s) Imperial / POB 47, 11 Boggs RD., PA. ; Southern Alleghenies / RDD « 3 Box 310, Valleyview, 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) 0 Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement t) ❑ Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application //~~~// 30 LOCATIONS OF ABATEMENT rA c 11D J '1k Z DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room #, (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 replaong boilers etc

ROOF ITEM NO. 3 ROOF, DUNNAGE, DUCTS 5,509 FACADE ITEM NO. 8 FRONT, BACK, COURT YD. 7,169

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 Engineers, P.C. Trio Asbestos Removal Corp. NYC Print Name of Air Monitor Print Name of Asbestos Contractor Print Name of p cant (If other than Owner)

Signature Signature Signature

(ti____ 6-2.a-o2-~_ Date Oate 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 C ntrol Program Rules. I have contracted the third party air monitor who is completely independent of all parties inv ved in JfI besto roject. I hereby declare that I have authorized the filing of this notification for the work specified herein. Building Owner / Manager do NYC __ _ _ '(' Print Name o,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 Control Program Rules may not be lawfully avoided or lessened through the performance of work in incremental or piecemeal fashion. ACP7 aaoot

NYC-WTC 000111472