Asbestos project notification form header, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) Asbestos 26. Asbestos Hauler Transportation CO. NYS DEC Permit # 1A-371 TEL.# 631-924-5050 Disposalsite(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 filing of this form with NYC Department of Buildings) a) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement f) ❑ 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 0 Tent ❑ DEP Variance Application j q 30. LOCATIONS OF ABATEMENT G 70~ L / /k 2, DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTI N OF WORK EING Floor(s) OF FLOOR CONTAINING ACM (e.g. entire, east wing, room p, SQUARE PERFORMED (e.g. Pipe lagging, ceiling, plenum R (e.g. running cable, installing fire sprinklers, boiler room, lobby, etc ducts, storaoe tanks, decking, etc.) FEET I FEET removing and replacing boilers, etc.) Facad Item No. 8 1artia1 Facade 12275

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 Rvl.Corp NYC Print Name of Air Monitor P of As s Contraaar Pant.Name of App' th than Owner)

vro~ ~u t (C Sign Signature ure

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32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible (or the performance of the asbestos abatement activities in accordance with the Asbesto o oI Program Rules. I have contracted the third party air monitor who is completely independent of all parties invol d ' t s stos proj ct. I hereby declare that I have authorized the filing of this notification for the work specified herein. 30 WSLLC c/o 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. of ram Rules may not or lessened I ACP7 in incremental or Di ?!loot

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