Invoice from Benjamin Kurzban & Son Control Inc., 111 Fulton

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler _ES ES I , NY NYS DEC Permit # N-1- 4 62 Tel.# (lie) 522-22G3 '

Disposal Sites) BLUE RIDGE LAND F I u.. P 0 BOX 399 S CoTs DALe PA 172 54

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/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 ''7 Titv,.► i-t:7 1 30. LOCATIONS OF ABATEMENT Qot)F MATEBtAL t SIDt4ES Cove2itlG, QooF MEtASP.& 3 DESCRIBE SECTION AFFECTED SURFACES AMOUNT OF ACM DESCRIPTION OF WORK BEING Floor(s) OF FLOOR CONTAINING ACM PERFORMED (e.g. entire, east wing, room #, (e.g. Pipe tagging, ceiling, plenum SQUAD LINEAR (e.g. running cable, installing fire sprinklers, boiler room, lobby. etc) ducts, stoeace tanks, decking, etc.) FEET FEET removing and replacing replacIng boilers. etc.) tN ROOF eOOF SuQFAeE. 18$80 SroNt3 ccvea.is4 eoetr MeueRAME n WuvE WAIL 1750 it M+~rat- 500 A& UNIT METAL SUPPoRiS 22~oa WOF S1.322ACE 1216

ttooFs ROOF Sja.c#c€ 799. 6 tt4DiYl1Upt_ SMAUJIM 0t~ois Lquvit 5 556 rNtua ;4

Ne uNi'i suppottts I390 !1(ETAt- A& SOPPoa.a

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31. 1 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.

WAi wt ?Au-lelz b 6, i N E'(~S B. kuiZZ6^Q 4 S0N CoWMOL Print Name of Air Mon' or Print N e of Asbestos fret Print Name of Applicant (If other than Owner)

Sign lure Signature Signature

C7-12-0 2 a7-12-02 Date Date 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 fill -this notification for the work specified herein. ry a NYC ' or-12 Print Name of Owner Signature Date

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

I_Any Modification of information rovided on this form must be re rted immediate) In writingdirectly to the NYC DEP ACP. The requirements of the Asbestos Control Program Rules may not be lawfully avoided or lessened throughtheperformance of work in incremental or iecemeal fashion. ACP7 212001

NYC-WTC 000128705