Asbestos project notification form, 100 Church Street area, undated

NYC 9/11 Public Portal Document

I

ASBESTOS INSPECTION REPORT (continued) .L. 26. Asbestos Hauler NYS DEC Pemut tI ~ Tel. ! cR _z72'- ;3 7 Disposal Site(s).

27. This asbestos abatement is part of a (Item a through a requires filing of this form with NYC Department of Buildings) a) 0 Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) 0 Fireproofing Replacement f) ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure 0 Encapsulation ❑ Repair ❑ Clean up 29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag 0 Tent ❑ DEP Variance Application 3n LACATIONS AF ARA CLAC& r DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g entire. east way. room I. (e.g. Pipe tagging, ee3i+p, plenum SOUARE LINEAR (e.g. r,avi g cable. instsninp fre sprinkla~e. boiler room lobby. etc) l, storge tanks. Oediing. etc.) FEET • FEET •flOVW.Q end repIaOAQ boilers, etc ~ try ~o Lo ro„v 5 03 (~ ` $qcD~. (o ('t ts ~ se 1e C UtjtZc btr ' s t5`tfo

31. I 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.

tl'-I.-i 4t 2 5 C~lv P an itor 4 • Name Contractor Print Nan of Ac ant (M Weer than Oner)

Srpru4xe nature Spnature

OC- 03 0 302 Date Date Dote

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. wit? is completely independent of all parties involved in the asbestos project. I hereby declare that I have authorized the Iifl9 ifica or the work specified herein.

Pmt Ar SiPv4in Date

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

this form in writino directly to of the may not be lawfully avoided or

NYC-WTC 000126545