204 BROADWAY 1001222, 79/21

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPQ ntinued)

28. Asbestos Hauler i i=S i, N °q'`_°i—•. NYS DEC Permit #_t4. -462. Tei.# (zt8) 5.22-;2263

DisposalSite(s) bwer-r~—afiE LAwDFtLL PO Box 399 S CISDAt.E PA 1(254

27. This asbestos abatement is part of a (item a through a 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) O Other (Describe)

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag O Tent ❑ DEP Variance Application '71 ,

wwI f^ A ?tntfc. nr A A %IG'kIT n.. ,.-» c a,, IA =&AMP-A&M l #. ) )V. L,vVn I I I w yr Honk cmcn i cn.c-•s- •• ,c..-.--..- - -- - — - -- - - -- _____________________________________

AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING DESCRIBE SECTION PERFORMED Floor(s) OF FLOOR CONTAINING ACM LINEAR (e.g. entire, east wing, room #, (e.g. pipe fagging, ceiling, plenum SQUARE (e.g. running cable, installing fire sprinklers. FEET ' FEET removing and replacing boilers, etc.) boiler room, lobby. etc) ducts, storage tanks, decking, etc.)

ROOF Sc f?e-AcE 119,26 wcwtles Uwe- S cms's P.CoF t' Qiu:..kc M b L.) M LS 504

f I

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

WAt "N PRaze^R EiJl~1L1 iZS i ti~RNtt3 Ki34'Z L Print Name of Air Monitor Print Name of Asbestos Contractor Print Name of Applicant (if other than Owner)

Signature Signature Signature

Q81CeIC2.. oeIc61C2. Date -- Date — Date

am responsible for the performance of 32. 1 understand that as the owner of a building where asbestos abatement activity occurs, I I have contracted the third party air the asbestos abatement activities in accordance with the Asbestos Control Program Rules. monitor who is completely independent of all parties involved in th asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein. D' O8 I- Icz Signature Date Pnnt Name of Owner AVAILABLE AT THE WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE writingdirectly to the NYC DEP ACP. An modification of informationprovidedonthisformmustbereportedimmediately in be lawfully avoided or lessened The requirements of the Asbestos Control Program Rules may notiecemeal fashion. through the performance of work in incremental or 242001

NYC-WTC 000123276