204 BROADWAY 1001222, 79/21

NYC 9/11 Public Portal Document

TO I C`11O (contsnu )

26., Abestors Hauler test, N' NYC DEC Permit # NJ - 462 T rs, 63

Disposal Site(s) 9. ga: Dtrt u LO) 399 5corst:A.LE q

27, This asbestos abatement is part of a (Item a through e requires filing of this form with NYC Department of Buildings) a) O Demolition b) O Boiler Replacement c) O Sprinkler Replacement d) O Renovation/Alteration e) ❑ Fireproofing Replacement f) 0 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 ❑ Tent ❑ DEP Variance Application

30. LOCATIONS OF ABATEMENT PCCF MATETz4fr = cc F PEP DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED SQUARE LINEAR (e g running cable, installing fire sprinklers. (e g. entire, east wing, room #, (e g. P pe lagging, ceiling, plenum ducts storage tanks, decking: etc. FEET FEET removin and re lacin boilers, etc boiler room, lobby_ etC)

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31. I hereby declare that the information prov,ded herein is true and complete to the test of my knowledge I am familiar with Federal, State and NYC laws and regulations app cable to asbestos related work.

PR&rN c zcp E~,E,rN tka i ANr►~ K~<zts.r cti .. R:i Pert Name of A r Monitor Part Name of Asbestos Cont cr Print Name of Applicant (!f other than owner)

...__ g Si gnatur t S, na.,, c Signature

CBtcr. Ic Ce, C6IC 2 nary p Dace Date

performance of 32. I understand that as the owner of a building where asbestos abatement activity occurs, I am responsible for the with Asbestos Control Program Rules I have contracted the third party air the asbestos abatement activities in accordance the 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. - / 'GZ _. — Date Print Name of owner signatur e WORK SITE. A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE directly to the NYC 0EP ACP. AnY modification of information rovided on this form must be reported immediately in writing avoided or lessened The requirements of the Asbestos Control Program Rules may not be lawfully Acar throu h the erformance of work in incremental or piecemeal fash „........ ._..__...w._..... ~-g--._._-~ ---- 2/200 ,

NYC-WTC 000123268