Asbestos project notification form, [date]

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) ST,WEST,NORTH,SOUTH_—_ NYS DEC Permit # Tel.# 26. Asbestos Hauler EA

Disposal Site(s) _ ---------------

filing of this form with NYC Department of Buildings) 27. This asbestos abatement is part of a (Item a through e requires c) 0 Sprinkler Replacement d) ❑ Renovation/Alteration a) 0 Demolition b) 0 Boiler Replacement !2!L!_____-----_.___---------___---------- e) 0 Fireproofing Replacement f) El Other (Describe) -

28. TYPE OF ABATEMENT (Check all appropriate boxes) 0 Encapsulation ❑ Repair El Clean up ❑ Removal ❑ Enclosure

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag 0 Tent ❑ DEP Variance Application 1' (4.- O3n z e 73, 30. LOCATIONS OF ABATEMENT I AMOUNT OF ACM DESCRIPTION OF WORK BEING DESCRIBE SECTION AFFECTED SURFACES CONTAINING ACM PERFORMED Floor(s) OF FLOOR SQUARE LINEAR (e.g. running cable, installing fire sprinklers, (e.g. entire, east wing, room #, (e.g. Pipe lagging, ceifng, plenum FEET FEET removing and replacing boilers, eta) boiler room, lobby, etc) ducts, storage tanks decking, eta ENTIRE 6501 SCOPE "B" 5TH APT. 510

Federal, and complete to the best of my knowledge. I am familiar with 31. I hereby declare that the information provided herein is true related work. ....A Al t' ln. .7LGLG a/14 I. 1 v wVv ranl,iatinnc nA ,......... u,,.. ...- annticahle _.,- ------- - to asbestos

JBH ENVIRONMENTAL, INC. JBH ENVIRONMENTAL, INC. COLE CONSULTING rint Name Contractor Print Name of Applicant (If other than Owner) Print N e of Air Monitor

nature Signature Signatu

Date Date Date performance of where asbestos abatement activity occurs, I am responsible for the 32. 1 understand that as the owner of a building I have contracted the third party air Asbestos Control Program Rules. the asbestos abatement activities in accordance with the the asbestos project. I hereby declare that I have authorized the monitor who is completely independent of all parties involved in filing of this notification for the work specified herein. ~A CIS sig>t~'t+ _ S ►_ ORB MANAGEMENT ~HN )~~'1At"-ii( ~1 b __ — oats Print Name of Owner AA G AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING be reported immediately in writing directly to the NYC DEP ACP. Any modification of Information provided on this form must not be lawfully avoided or lessened The requirements of the Asbestos Control Program Rules may thrni lnh thA nArformance of work in incremental or iecemeal fashion. ACP7 212001

NYC-WTC 000115469