Asbestos project notification form, [date]

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) F_gST,WEST,NORTH,SOUTH —_ NYS DEC Permit # __—___ _______ Tel.# 26. Asbestos Hauler -----------_ ------- ------------ - Disposal Site(s) -------------- of this form with NYC Department of Buildings) 27. This asbestos abatement is part of a (Item a through a requires filing c) 0 Sprinkler Replacement d) 0 Renovation/Alteration a) ❑ Demolition b) 0 Boiler Replacement SCOPE "B" —__—_____—_—___________—____—_—___ e) ❑ Fireproofing Replacement f) 0 Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Enclosure 0 Encapsulation 0 Repair 1 I Clean up ❑ Removal

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag 0 Tent ❑ DEP Variance Application

30. LOCATIONS OF ABATEMENT 1'4& 0313 Hk,03. AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING DESCRIBE SECTION PERFORMED Floor(s) OF FLOOR CONTAINING ACM SQUARE LINEAR (e.g. running cable, installing fire sprinklers, (e.g. entire, east wing, room #, (e.g. Pipe tagging, ceiling, plenum FEET FEET removing and replacing boilers, etc.) boiler room, lobby, etc) ducts, storage tanks, decking, etc) ENTIRE 650 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 work. 0ss......A nlvr i~..,c and ran, lotions annlicable to asbestos related

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

nature Signature — -~ Signatu

--- _s _____— Date Date

abatement activity occurs, I am responsible for the performance of 32. I understand that as the owner of a building where asbestos Control Program Rules. I have contracted the third party air Asbestos the asbestos abatement activities in accordance with the asbestos project. I hereby declare that I have authorized the monitor who is completely independent of all parties involved in the filing of this notification for the work specified herein.

ORB MANAGEMENT `fQKN_~L_L' "►__iatL—~-""" Signature - — t Print Name of Owner rr^ A

MUST BE AVAILABLE AT THE WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS reported immediately in writing directly to the NYC DEP ACP. Any modification of information provided on this form must be not be lawfully avoided or lessened The requirements of the Asbestos Control Program Rules may piecemeal fashion ACP7 through the performance of work in incremental or

NYC-WTC 000115471