179 BROADWAY 1001076, 63/18

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos Hauler CO 0 NYS DEC Permit "O Tel. /~~~ - 72-.3 7 e / Disposal Sites) U (1€&P t/~ 5 ! !~ j'

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) ❑ Boller Replacement C) 0 Sprinkler Replacement • d) ❑ Renovation!Alteration e) 0 Fireproofing Replacement f) ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair ❑ Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment 0 Glovebag ❑ 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 #. (e.g. Pipe lagging. ceiling plenum SQUARE UNEAR (e.g. running table, installing rue sprinklers, boiler room, lobby, etc) ducts, storage tanks, ded&ig4 etc.) FEET ' FEET removing and raplacinq boilers. eta)

31. I hereby declare that the information provided herein is true and complete to the best of my knowledge. I amlamiliar with Federal, State and NYC laws and regulations applicable to asbestos related work.

bsu~ tF~t~c fi /vi ___________

Print N r itor Pun Name os Contractor Print Nam of App nt (If other than Owner)

Signature nature Signature

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 otif,catioo4or the work specified herein.

Pnru Name or Ow er - Signature Date

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

II Any modification of information pcovcSed 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 Acvr Z2oot

NYC-WTC 000122777