Asbestos project notification form

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) ❑ 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 ❑ Enclosure ❑ Encapsulation ❑ Repair El Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent tEl DEP Variance Application 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, roan #, (e.g. Pipe tagging, calling. plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers, boiler room, lobby, etc) ducts, storage tanks, decking, etc.) FEET FEET and replacing boilers, etc.) Fifth partment PU j 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 farXtiliar with Federal, State and NYC laws and regulations applicable to asbestos related work. I Athenica Environmental Services Ii Specialty Service Contracting Inc. USEPA < AJ , Print Name of Air Monitor Print Nam cos Contractor Print Name of Applicant (if other than Owner)

Signature Signature Signature

1/23/03 1/23/03 1/23/03 Date Date 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 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 immediately in wilting 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. 212001

NYC-WTC-000116313