Asbestos Project Notification form, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) Asbestos 26. Asbestos HaulerTransport-ation Cr . NYSDECPermit# 1A-371 TEL.#631-924-5050 •Disposal Site(s)Imperial/POB 47, 11 Boggs Rd., PA: Southern Alleghenies/Rd 3 27. This asbestos Valleyview Dr., PA 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 0 ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure 0 Encapsulation ❑ Repair ❑ Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application

30. LOCATIONS OF ABATEMENT

Floor(s) DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM 1 O DESCRIPTION OF WORK 6 lt7G oz., 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.) FEET FEET removing and replacing boilers, etc.) Roof Item No. 2 Roof and uncov- 3000 ered surfaces

Wall Item No. 7 artja1 Bulkhead 800 & Parapet Walls

Facadt Item No. 7 Partial West 2250 Facade

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 Print Name of Air Monitor NYC Prim ame b nlraCtor Print Name of Applicant (If other than Owner)

~4 ~1 Signature Signature Signature

t: 26 o? ate Oa(e 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 inv dint a estos project. I hereby declare that I have authorized the filing of this notification for the work specified herein. 1

Print Name of Owner Signature Oale

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

LAny modification of information provided on this form must be reported immediately in writing directly to the NYC DEP ACP.III The of the Asbestos Control Program Rules may not be lawfully avoided or lessened ACP7 ugh the performance of work in incremental or piecemeal fashion 212001

NYC-WTC 000111505