NYC 9/11 Public Portal Document
ASBESTOS INSPECTION REPORT (continued)
..._. .
rt26. Asbestos Hauler _C/O N'fS DEC Permit —o f oc ~7Z"3~'o'~'
Disposal Site(s) _ U eQ .PTV uo s . \/ (( ( Tel. /—./
27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) v _•' ' •'
a) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/A(tdration
e) ❑ Fireproofing Replacement t) ❑ 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 0 Glovebag ❑ Tent ❑ DEP Variance Application
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30. LOCATIONS OF ABATFMFnIT ti • •
DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING
Floor(s) OF FLOOR CONTAINING ACM PERFORMED
(e.g. entire, east wing, room tt, (e.g. Pipe tagging, ceiling, plenum SQUARE LINEAR '(e.g. running cable, installing fire sprinklers,
boiler room, lobby, etc) ducts, store a tanks. decking, etc.) FEET FEET removing and replacing boilers, etc.)
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.
4 _t tit A f /v C17() 4 ,v I 7~1i (
Pint N r itor Prin Name f As stos Contractor Print Nam of App ant (If other than Owner)
r
Signature gnature Signature
Date Date 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
filir of this notifica N n for the work specified herein.
Print Name f 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.
The requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened
through the performance of work in incremental or piecemeal fashion. J ACPr
2!2001
NYC-WTC 000114487
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