Asbestos project notification form, 100 Church Street

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler Lt7 o NYS DEC Permit _ Tel. O - 27Z- 3 ? Disposal Site(s) UI e2 N • l~E ~e~ to 5 IQ'( / /- '( 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) 0 RenovatiorVAlteration a) ❑ Fireproofing Replacement f) ❑ Other (Describe)

28. TYPE OF ABATEMENT (Check all appropriate boxes) ❑ Removal ❑ Enclosure 0 Encapsulation 0 Repair 0 Clean up

29. ABATEMENT PROCEDURE (Check all appropriate boxes) 0 Full Containment ❑ Glovebag 0 Tent 0 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 /. (s.g Pve tagging. lerg. plerxx►+ s0UARE LINEAR (eg muting able. iutaung fro sprinklers, boiler room. by..tc tluW. st tanks. d.dç. etc.) FEET nlrrxrvi and reari boilers. etc)

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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.

P vn N eor Pnn Name star Contractor Print Na- o/ App nt (H Other than Owner)

t T Sgna urs ______

nauae _______

Sgnature

Date ate 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 f this.notif}ratio r the t: cified herein.

Prru Named r S+gnstus Date

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

EjilArty modification of information provided 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. sraoot

NYC-WTC 000126769