Asbestos Project Notification form, Oct 2001

NYC 9111 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26.•Asbestos Hauler __ NYS DEC Permit # _ _ TEL.#

Disposal Site(s) __

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) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) 0 Renovation/Alteration e) 0 Fireproofing Replacement Q ❑ 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 G 30. LOCATIONS OF ABATEMENT ~~AL/ dfd ~~ 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 ff, (e.g. Pipe tagging, ceiling, plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers, boiler room, lobby, etc) ducts, store a tanks, decking, etc.) FEET FEET removing and replacing boilers, etc.)

oof Item No. 1 3405 Walls Item No. 7 920

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 and Panzer Trio Asbestos Removal NYC Print Na f Air Monitor Prin a f As s Contractor Print Name of Applicant (If other than Owner)

nature Signature Signature

6-' & y fi. Oate 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 Contr Program Rules. I have contracted the third party air monitor who is completely independent of all parties involved' t sb s project. I hereby declare that I have authorized the filing of this notification for the work specified herein. Stahl Midtown Property do NYC '1~ Z Print Name of Owner Signature l Oat

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 OEP 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. 2/2001

NYC-WTC 000111480