Asbestos Project Notification form, Oct 2001

NYC 9/11 Public Portal Document

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

Disposal Sites) 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) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement I) ❑ 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 O 41O Z 30. LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room p, (e.g. Pipe lagging, ceiling, plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers, boiler room, lobby. etc) ducts s oro a tanks. deckin . etc.) FEET FEET removing and replacing boilers. etc.)

oof Item No. 1 ncovered Surf. 1990 acade Item No. 7 acades 3285

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 Print Name of Air Monitor Pan ame of Asbe o ontractor Print Name of Applicant (If other than Owner)

// 1p1J Signature Signature Signature

31 i 2 7/3f/O2_- Date ate 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. Nick Spyreas Enterprises, LLC fLIt ` . 7/.V/a2._ Print Name of Owner C o NYC Signature Date

A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.

I 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 I through the performance of work in incremental or piecemeal fashion. j 2/1001

NYC-WTC 000111456