Asbestos Project Notification form, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) sbesos 26. Asbestos Hauler ' r arispOrta Lion CO. DEC Permit # 1A-371 TEL;#631-924-5050 oisposalSite(s)Imperial/POB 47, 11 Boggs Rd., PA: Southern Alleghenies/Rd 3 27. This asbestos abatement Is part of a (Item a through a requires filing of this form with Valleyview Sr., NYC Department of Buildings) PA a) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration a) ❑ Fireproofing Replacement 0 Other (Describe) 0 28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair ❑ Cleanup 29. ABATEMENT PROCEDURE (Check all appropriate. boxes) ❑ Full Containment 0 Glovebag ❑ Tent ❑ DEP Variance Application h a Oy 30. LOCATIONS OF ABATEMENT DESCRIBE SECTION • AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM (e.g. entire, east wing, room p, (e.g. Pipe lagging, ceiling, plenum SQUARE LINEAR PERFORMED (e.g. mmnirig cable, inslaling fire sprinklers, boiler room, lobby, etc) ducts, store a tanks, deckin , etc.) FEET FEET removing and replaanQ boilers, etc.) Roof Item No. 1 ksphalt Roof 1875

acade Item No. 7 East Facade 1725 P

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.Cor NYC Print Name or 'r Monlor P' Name of Asb cTContractor Print Name off v nt (It other than Owner)

Signature Signature Signature

2 - 6Z_oz—. Date Date Date

32. I understand that as the owner of a building where asbestos abate t acti 't rs, I am responsible for the performance of the asbestos abatement activities in accordance with the As stns t of ogram Rules. I have contracted the third party air monitor who is completely independent of all parties involy d n e a proje . I hereby declare that I have authorized the filing of this notification for the work specified herein. C/ O Lori

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Corp. d o n

NYC 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. requirements of the . may or ACP7 through the ?!2001

NYC-WTC 000111478