NYC 9/11 Public Portal Document
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ASBESTOS INSPECTION REPORT (continued)
26. Asbestos Hauler ( 0 NYS DEC Permit rO( Tel. ~8~/ ~~? 2~3
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Disposal Site(s) O ek Fv 1E rI e 5 !"^ ,!
27. This asbestos abatement Is part of a (Item a through e requires filing of this form with NYC Department of Buildings) fi
a) ❑ Demolition b) ❑ Boller Replacement C) 0 Sprinkler Replacement d) ❑ Renovation/Alteration
e) ❑ Fireproofing Replacement f) ❑ Other (Describe)
28. TYPE OF ABATEMENT (Check all appropriate boxes)
❑ Removal ❑ Enclosure 0 Encapsulation ❑ Repair 0 Clean up
29. ABATEMENT PROCEDURE (Check all appropriate boxes)
❑ Full Containment ❑ Gtovebag 0 Tent ❑ 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. room U. (e.g. Pipe legging. ceiling. Plenum SQUARE LINEAR (e.g. running cable, installing fire sprinklers,
baler room . etc) ducts. storage tanks, decking, etc.) FEET ' FEET removing and replacing balers, etc.)
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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. "r
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Pant N itor P' Name stos Contractor Print Na . of App nt (If other than Owner)
Signature
. _______
gnature
_______
Signature
~~- 03 0a --02.
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 th notificatio for the work specified herein.
'PrW Nsrne 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 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. ;,
212001
NYC-WTC 000119771
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