Asbestos project notification form, DEP, undated

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler Tri State Transfer/ATc NYS DEC Permit # 1A-75/1A-371 TE Disposal Site(s)GGreenridge Landfill, 1 Landfill Rd, Scottsdale, PA / Meadowfill Landfill, RI 27. This asbestos abatement Is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) 0 Demolition b) ❑ Boiler Replacement c) 0 Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement f) El Other (Describe) Environmental Clean Up

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair El Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application

30. LOCATIONS OF ABATEMENT -ilk.. i tJlU Mj..u f DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room #, (e.g. Pipe lagging, oiling, plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers, boiler room, lobby, etc) ducts, storage tanks, decking, eta) SE removing and replacing boilers, etc.) PH 3 Entire Debris Clean Up 534 Environmental Clean Up PH 2 Entire Debris Clean Up 3,638 Environmental Clean Up PH 1 Entire Debris Clean Up 5,741 Environmental Clean Up 21 Entire Debris Clean Up 13,738 Environmental Clean Up 20 Entire Debris Clean Up 13,738 Environmental Clean Up 19 Entire Debris Clean Up 14,174 Environmental Clean Up 18 Entire Debris Clean Up 14,174 Environmental Clean Up 17 Entire Debris Clean Up 21,489 Environmental Clean Up 16 Entire Debris Clean Up 21,489 Environmental Clean Up 15 Entire Debris Clean Up 24,805 Environmental Clean Up

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.

EM & CA Pinnacle Environmental Corp Pinnacle Environmental Corp Print Name of Air Monitor Print Name of Asbestos Contractor Print Na of Applicant (If other than Owner)

3 S~ tore

Date j C ' Signatue

i!/)t c( Date 'J ur Signature

Date

32. 1 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 asbesto prof . I hereby declare that I have authorized the filing of this notification for the work specified herein. Lions Head 110 Development LLC c/o Worldwide //24' O/ Print Name of Owner Holdings Inc ign ure Date

A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.

I 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 ACP7 through the performance of work in incremental or piecemeal fashion. 22001

NYC-WTC 000115930