Invoice, Benjamin Kurzban & Son, Sep 2002

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

• 26. Asbestos Hauler IESI . NY NYS DEC Permit # U - 462 Tel.# C'1(S) S22-22C.3

Disposal Site(s) BwIE WDEia LAMDFtU. PO Box 399 SCo't5'DRLE PA I't254'•

27. This asbestos abatement Is part of a (Item a through a requires filing of this form with NYC Department of Buildings) a) ❑ Demolition b) ❑ Boiler Replacement c) O Sprinkler Replacement d) O Renovation/Alteration e) O 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 O Tent ❑ DEP Variance Application

Qn I At ATIAIJC nF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. Pipe lagging. calling. plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers. (e.g. entire, east wing. room >l. boiler room. lobby, etc) decd etc.) ducts, storage tanks. , FEET ' FEET removing and replacing balers. etc.

ROOF P-Oof Svl✓FACE 2522

S _ _ Pr0F Se AC. 126 it Ale 4 fA t_ 1OOO

FACApe E -eST t FACAOE SuR pF .e ` 2C BO tt WeSli i~res'V iAe, 2340 Ft Pic ESCAP4c"`.. 2-I cc

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.

wpguem I Pc i z tw If ere-e S "B. 2 6At3 4 Soy; t r~► -U-L Print Name of Applicant (If other than Owner) Print Name of Air Monitor Pit ame of nos Contractor

ai% Signaturet€7 , Signature Signature

C'9_C5-C2 09-G'S-c2 -~ Date Date Date

performance of 32. 1 understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the the third party air the asbestos abatement activities in accordance with the Asbestos Control Program Rules. I have contracted authorized the monitor who is completely independent of all parties involved in the asbestos project. I hereby declare that I have filing of this notification for the work specified herein. S ~ .' ...uyct3En Q)l I OS te2 Signature Date Print Name of Owner SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK NYC DEP ACP. Any modification of information provided on this form must be reported immediately in writing directly to the lessens The requirements of the Asbestos Control Program Rules may not be lawfully avoided or ACP7 through the performance of work in incremental or piecemeal fashion. 2f=t

NYC-WTC 000115230