Asbestos project notification form for 250 South End Ave

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler _IE$ ______ ___ _____ NYS DEC Permit # NJ 462 Tei.# 71 8 - 5 2 2 - 2 2 6 3 Disposal Site(s)__=ESI_Pa Blue Ridge_Land Fill CorgiN Scotland Pa 17254

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) 0 Sprinkler Replacement d) 0 Renovation/Alteration e) 0 Fireproofing Replacement f) K] Other (Describe) Emergency Clean—up _.__ 28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure 0 Encapsulation ❑ Repair Clean up

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 Glovebag ❑ Tent 13 DEP Variance Application

30. LOCATIONS OF ABATEMENT - DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM bESCRIPTTON OF WORK EING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room p, (e.g. Pipe lagging, calling. plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers. boiler room, lobby, etc) ducts, stoome tan ks. deck . etc.) T removino and reladng boilers etc.)

round Court Yard Soil and Pavers 9,375 Clean up of Asbestos

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.

-E i-r, ----_.--_ om En-vira n al-Manag.Bm rlt-_Environmental Manag ment I Pnnt it Monitor nt N of Asbestos Contractor S r rJe®f slipnt (If other than Owner) o o So 1 u L 1

* `—"?=~ r ''~J ------- rgnature Signature Signature

Da/'J____________________ te 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'C of Program Rules. I have contracted the third party air monitor who is completely independent of all parties involved !'the stos project. I hereby declare that I have 3uthorized the ling of this notification forthe work specified herein. /

PrirtrName of Owner J ci1 / / Signature /// Date

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

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 through the performance of work in incremental or piecemeal fashion. ACP7 212001

NYC-WTC 000117406