NYC 9/11 Public Portal Document
DEP ECB Fax:212-361-1433 Jun 28 2002 11:24 P.04
ASBESTOS INSPECTION REPORT (continued)
' 72~ 3 7
26. Asbestos Hauler -- co NYS DEC Permit Tet.q•
Disposal Site(s)
NYC Department of Buildings)
27. This asbestos abatement Is part of a (Item a through a requires filing of this form with
b) ❑ Boiler Replacement c) ❑ Sprinkler Rept acament • d) ❑ Renovation/Alteration
a) 0 Demolition
a) ❑ Fireproofing Replacement f) ❑ Other (Describe) -_
28. TYPE OF ABATEMENT (Check all appropriate boxes;
❑ Remove! ❑ Enclosure 0 Encapsulation ❑ Repair ❑ Clean up
29. ABATEMENT PROCEDURE (Check all appropriate boxes)
❑DEP Variance Application ' Q y
❑ Full Containment 0 Glovebag ❑Tent
30. LOCATIONS OF ABATEMENT
5CRIPrION OF WORK EING
DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM
Floor(s) OF FLOOR CONTAINING ACM LiNt:AR (e.g. runningPERFORMED
cable, inilsNing firs eprinkbn.
(e.g. entire. last wtnQ, room a, (e.g. pit. tagging atting. plenum SQUARE
FEET ' FEET rein end r.pledn boilers etc.
boiler lob C) ducts. storsee i*u ds i , etc•)
___ ________
01 -
i 1
I am familiar with Federal,
31. 1 hereby declare that the Information provided hereir is true and complete to the best of my knowledge.
State and NYC laws and regulations applicable to asbestos related work.
Print t~t or
ii: Pin Nams As
c~iT7
stow GontraCt Print Na of APP (if other than Owner)
mature Signature
Signature
C,- 03 oa . '3-c)
err responsible for the performance of
s2. I understand that as the owner of a building where asbestos abatement activity occurs, I the third party air
the asbestos abatement eclivities 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
filingAof this n~fication for the work specified herei —
` Date
--- Print Nome or Owner Signature
A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.
to the NYC DEP ACP.
[_Any modification of Information ørovided n this form must be reported immediately in writing directly lessened
The requirements of the Asbestos Control Program Rules may notleceme
be lawfully avoided or
1 fashion:
through the oerformertce of Work in in mental or t
NYC-WTC 000115959
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