Asbestos Project Notification form, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) Asbestos 26. Asbestos Hauler ransportation --• CO_ NYS DEC Permit # 1A-371 TEL.# 631 -924-5050

Disposal Site(s)imperial/POB 47, 11 Boggs Rd., PA: Southern Alleghenies/Rd 3 Valleyview Dr., PA 27. This asbestos abatement is part of a (Item a through e requires riling of this form with NYC Department of Buildings) a) ❑ Demolition b) ❑ Boiler Replacement c) 0 Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement f) ❑ Other (Describe)

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 /O

30. LOCATIONS OF ABATEMENT ~ Ots - DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room X. (e.g. Pipe lagging, ceiling, plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers, boiler room, lobby. etc) ducts, storage tanks, decking, etc.) ET FEET removing and repladng boilers, etc.

Roof Item No. 2 Asphalt Roof 3600 aca a I,üi aJo. 7 Fa ales No so F. Soo

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 rio Asbestos Rmvl.Crp NYC P,pint Name of Air Monitor P a f s Contractor Print Name of Applicant (If other than Owner)

O4"Lv Signature 6G:~L Signature Signature

' S .

Date , /2. Date ate _______________

32. I understand that as the owner of a building where asbestos abateme ivi occurs, I am responsible for the performance of the asbestos abatement activities in accordance with the As stns ontr P gram les. I have contracted the third party air monitor who is completely independent of all parties involy d n e asb o pro' "ereby declare that I have uthorizd the filing of this notification for the work specified herein. C/o NYC DZ Print Name of Owner Signature 0at4

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 ACPIII The requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened ACP7 through the performance of work in incremental o( piecemeal fashion. 22001

NYC-WTC 000111458