Asbestos project notification form, Jan 2003

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler DJM Inc. NYS DEC Permit # NJ344 TEL.# (201) 635-1551 Disposal Site(s) Imperial Landfill Route 980 and Boggs Road, Imperial PA 27. This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) ❑ Demolition b) 0 Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement f) El Other (Describe) Suspect WTC Dust Cleanup

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal 0 Enclosure ❑ Encapsulation ❑ Repair 21 Clean up

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag 0 Tent (21 DEP Variance Application ©j ~ry'" _ }o -3 ~, I/}/~ N 30. LOCATIONS OF ABATEMENT 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 tagging, caning, plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers. boiler room , eto) ducts, storage tanks, decking, etc.) FEET FEET removing and repladng boilers, etc.)

Fifth Apartment PI I Clean All Surfaces WTC ARD Scope B

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. I{ Athenica Environmental Services ii Print Name of Air Monitor Specialty Service Contracting Inc. ~~/Pri `m toe Contractor USEPA Vi-" Print Name of Applicant (if other than Owner) v~ f Signature Signature Signature

1/23/03 1/23/03 1/23/03 Date Date Date

32. I 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 asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein.

Print Name of Owner Signature Date

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

Any modification of information provided on this form must be reported immediate!y in writing direct!y 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. 2/2001

NYC-WTC-000116311