Asbestos project notification form for 250 South End Ave

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler IESI ________________ ____ NYS DEC Permit # NJ 462 Tel.# 718-522-2263 DisposalSite(s) IESIPa Blue Ridge Land Fill Corte. _Scotland_ 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) K] Other(Describe)Emergency Clean-up

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair [3 Clean up

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

30. LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM ..". f 8 >/1% 1c.". ESCRIP ON OF WORK EING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room #. (e.g. Pipe lagging, ceiling, plenum SQUARE UNEAR (e.g. running cable, installing fire sprinklers, boiler room, lobby, etc) ducts, storage tan ks, deckk' , etc FEET FEET removing and replaoing boilers, etc.)

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

31. 1 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.

.Emv ronmental-Managem nt_En_v__ironmental_Manag Bment l'nM o r Monica• t of Asbestos Contractor Sdt si1 t (if other than Owner) S lu~T~ — ugnature — Signature Signature

Date Date //%~ Date 1 ___________

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

Pri Name of owner Date

A STAMPED COPY OF THIS FORM INCLUDING4ENDMENTelturel.IST 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. ACPi 212001

NYC-WTC 000117412