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/POE 47, 11 Boggs Rd., PA: Southern Alleghenies Valleyview Dr., PA 27. This asbestos abatement is part of a (I(em 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) 0 Fireproofing Replacement t) ❑ Other (Describe)

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

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

30. LOCATIONS OF ABATEMENT 112.11.111/06 YNA, C~ z DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF W RK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room k, (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 F$ET removing and replacing boilers, etc.) Roof Item No. 1 Asphalt Roof 1,200

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. NYC rint Name of Air Monitor Pri Na Asbe Contractor Print Name cant (If other than Owner)

Signature fj Signature Signature

? - '_ O2 2cf~ 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 Asb,estos ntrol Pro ram Rules. I have contracted the third party air monitor who is completely independent of all parties inv din sbe oject. I hereby declare that I have authorized the filing of this notification for the work specified herein.

Print Name of Owner Signature 7 3 0 e

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 ACP7 through the performance of work in incremental or piecemeal fashion. 21200'

NYC-WTC 000111474