Asbestos project notification form, Zone III Originals

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT continued r Soes os ~r(ansportation 26. Asbestos Hauler CO . NYS DEC Permit # 1A— 3 71 TEL.i6 31- 9 2 4 - 5 0 5 0 DisposalSite(s) Imperial/POB 47, 11 Boggs Rd., PA; Southern Alleghenies/Rd 3

27. This asbestos abatement Is part of a (Item a through e requires filing of this form with NYC PA view Department of Buildings) a) ❑ Demolition b) 0 Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement I) 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 DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM I DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM (e.g. entire, east wing, room tl, (e.g. Pipe tagging, ceiling, plenum SQUARE PERFORMED baler mom. lobby, etc) LINEAR (e,g, tunning cable, installing fire sprinklers, ducts, storage tanks, decking. etc.) FEET FEET removing and replacing boilers, etc.) oof Item No. 2 3250

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.

arren & Panzer Trio Asbestos Removal Print Name of AhiMo+nitor NYC Print Name of As tos red Pri Name (Applicant (if other than Owner)

/ Signature Si~grn-ature Signature f/

Oate Oate Oate 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 t asbestos riling of this notification for the work specified herein. project. I hereby declare that I have authorized the

Time Equities C/o NYC Print Name of Owner Signature I Date A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. LA ny modification of information provided on this form must be reported immediately in wilting directly to the NYC DEP ACP. requirements of the Asbestos Control Program Rules may not or ACP7 through the performance of work in incremental or ci 2/2001

NYC-WTC 000111509