Asbestos inspection form, 125 Barclay Street

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler Asbestos Transportation Corp_ NYS DEC Permit # 1A371 Tel.# (631) 924-5050 Disposal Site(s) Meadowfill Landfill, Bridgeport, WV 26330

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) 0 Other (Describe) Asbestos Abatement / Cleanup

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation 0 Repair El Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ DEP Variance Application

30. LOCATIONS OF ABATEMENT It /3 ft P~~L.M DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION Q ORK BEING Floor(s) OF FLOOR CONTAINING ACM (e.g. entire, east wing, room #, (e.g. Pipe lagging, coiling, plenum SQUARE PERFORMED LINEAR (e.g. running cable, installing fire spnnklers, boiler room, bbb , etc)- -_- ducts, storage tanks, deddng, elc. FEET FEET removing and replacing boilers, etc.) 10th floor North & South MER Horizontal Surfaces 150 0 Asbestos Abatement 7th floor North MER Horizontal Surfaces 70 0 Asbestos Abatement 5th floor North MER Horizontal Surfaces 70 0 Asbestos Abatement 3rd floor South MER Horizontal Surfaces 80 0 Asbestos Abatement

31. I hereby dedare 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.

HA Bader Consultants Inc. Don Adler for Safeway Env Corp. Don Adler for Safeway Env Corp. Print Name of Air Monitor Print Name bestos Contractor Print Name of Appli ,other than Owner)

Signature Sig

11/21/01 11/21/01 11/21/01 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 r the work specified herein. / 11/21/01 Print Name of wnerI ` ign 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 wrn directly to the NYC DEP ACID . I ,.._

~ 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 000119418