NYC 9/11 Public Portal Document
DEP ECB Fax:212-361-1433 Jun 28 2002 11:26 P.07
ASBESTOS INSPECTION REPORT (continued)
9'Ot~
28. Asbestos Hauler NYS DEC Permit —Z .& 7
Disposal Sites) ~2 !tE ~ * "O1t0ru
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/Atteration
a) 0 Fireproofing Replacement fl ❑ Other (Describe)
28. TYPE OF ABATEMENT (Check all appropriate boxes)
❑ Removal ❑ Enclosure ❑ Encapsulation ❑ Repair ❑ Clean up
29. ABATEMENT PROCEDURE (Check aU appropriate boxes)
0 Fun Containment ❑ Gtovebag ❑ Tent ❑ DEP Variance Application
30 LOCATIONS OF ABATEMENT a/ /
DESCRIBE SEC !ON AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING
Floor(s) OF FLOOR CONTAINING ACM PERFORMED
SOUARB LINEAR tag. running cable, inet$iling itro sp.nklers,
(a.y. entire, Baal wing. room #. (e.g. pipe lagging. cesng, plenum FEET reiwvine sf4 rpIacfng boOera eta
baser room,1 aueti, storage tanksdSøcfrO, t0 P55?
19
Federal,
31. ! hereby declare that the information provided herein Is true and complete to the beat of my knowledge. I am familiar with
State and NYC laws and regulations applicable to asbestos related work.
P1nt N Itor Pri Name As aloe conlraetor Print Nam of Ap t (H oNer than Owner)
neturo Sgneturs
Signature
t
for the performance of
32. 1 understand that as the owner of a building whore asbestos abatement aotivity occurs. I am responsible contracted the third party air
the asbestos abatement activities In accordance with the Asbestos Control Program Rules. I have
project. I hereby declare that i have authorized the
monitor who is completely independent of all parties involved in the asbestos
filing of this notification for the work specified herein.
bale
Print N of Owner $ipnavre
AT THE WORK SIZE.
A STAMPED COPY OF THIS FORM INCLUDING AMENDMENTS MUST BE AVAILABLE
directly to the NYC PEP ACP.
I Any modification of in on provided on this form must be reported Immediately In writing
requirements
or
N( 1
21001
NYC-WTC 000127309
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