NYC 9/11 Public Portal Document
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ASRESTOS INSPECTION REPORT (continued)
26. Asbestos Hauler _LO NYS DEC Permit t CTO1 .Tel. /'U~ ^ 272 7
Disposal Site(s) Q +~~ Ne 5 ( !~ .1(
27. This asbestos abatement is part of a (Item a through s requires filing of this forth with NYC Department of Buildings)
a) ❑ Demolition b) ❑ Boiler -Replacement c) (1 Sprinkler Replacement d) ❑ Renovation/Alteration
e) 0 Fireproofing Replacement t) ❑ Other (Describe) _
28. TYPE OF ABATEMENT (Check all appropriate boxes)
0 Kemovel *❑ Enclosure ❑ Encapsulation ❑ Repair ❑ Clean up
29. ABATEMENT PROCEDURE (Check all appropriate boxes)
0 Full Containment ❑ OloveDag ❑ Tent 0 DEP Variance Application O
30. LOCATION$ OF ABATEMENT A v
DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCF TlON OF WORK BEING
Floor(s) OF FLOOR CONTAINING ACM PERFORMED
(tq. entire, 55t Mng. room i4. (e.p. Pips lagging, ceiling, plenum RE
solar room lo . 1c) du a tanks. d $OU FEET (e.g nrnning Cable. irutal ing firs sorinklent.
end rsplaciflq tamers. etc.)
tc. LAii, r U_________ ___ ___ -
5 0
31. I hereby declare that the information provided herein is true and complete to the best or my knowledge. I am familiar with Federal,
State and NYC laws and regulations applicable to asbestos related work.
Print 'tor P ' Name Alb toe Conlncter
A)1/'k4(
Prtnt Na of Apo (N other then Owner)
8ignaWre nature Signature
0.11 Date Oats
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 notif tion for the work specified here
l
Pmt N/ml f OMrMr Sigrhelure ~— Oele
A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE AT THE WORK SITE.
[Any modification of information provided on this form mtist be rgp1ed lmm diatel In writingdireciy to the
The requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened
Ihrouqh the performance of work inincremental or i meal fashion. AcP;
5200'
NYC-WTC 000126290
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