NYC 9/11 Public Portal Document
ASBESTOS INSPECTION REPORT (continued)
26. Asbestos Iirauter~, g Jf" t0 Z72-3 '
Disposal Site(s)
27. This asbestos abatement is part of a (item a through a requires filing of this form w6 NYC
Department of BulicTings)
a) ❑ Demolition b) ❑ Boiler Replacement C) ❑ Sprtnkler Replacement • d) ❑ RenovatioNAtteration
e) 0 Fireproofing Replacement .1) ❑ Othef (Describe)
28. TYPE OF ABATEMENT (Check all appropriate boxes) 4
❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair ❑ Clean up
29. ABATEMENT PROCEDURE (Check all appropriate boxes)
❑ Fur Containment ❑ Glovebag
30. LOCATIONS OF ABATEMENT
❑ Tent ❑ DEP variance Application
17,2,,t.)02w
DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING
Floor(s) OF FLOOR . CONTAINING ACM
wing. (e.g. plenum LiNEAR PERFORMED
to ballet room (e.g. n v*ig cable, installing Gne spiinklerL
a S. stor c. . EEMM
T •
SQUARE and boilers. etc
M
~ b3a
31. 1 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.
p'
/ c
' Name
) ci;
Asbestos Contractor
c
Print Na . of Ai4ant (n other than Owner)
. r S Signature
Date Date Date
32. 1 understand that as the owner of a building where asbestos abatement
activity occurs, tam responsible for the performance of
the asbestos abatement activities in accordance with the Asbestos Control Program
• monitor who is completely independent of all parties Inyolved In the bestos project.Rules. I have contracted the third party air
I hereby declare that I have authorized the
filing of tfiii$ notification for the work specif' red ` ' , µ~_ f W7C
Pant Name of owner
h v4'dL fo eye7.
Ana ~
. -i U
A $TAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE
WORK SITE.
[ilAnY modification of information provided on this form must be reported immediately In writing
directly to the NYC DEP ACP.
i ne requirements of the Asbestos Control Program Rules may
not be lawfully avoided or
AGP7
arloot
NYC-WTC 000115837
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