Asbestos project notification and inspection report form

NYC 9/11 Public Portal Document

ASBESTOS INSPECTION REPORT (continued) 26. Asbestos HaulerAsbestos NYS DEC Permit # 1 A- 3 71 TEL.# .fL31-92— 5.Q5Q Disposal sites) m erial POB 47. 11 Boggs Rr1 PA, Southern Al le henies Valleyview r Meg ow~ an i , Rte 2, Box 68 27. This asbestos abatement is part of a (item a through e requires filing of this form with NYC Department ofBud ng s WVA a) ❑ Demolition b) ❑ Boiler Replacement c) ❑ Sprinkler Replacement d) ❑ Renovation/Alteration e) ❑ Fireproofing Replacement t) 9] Other (Describe) Scope B Work WTC Indoor Dust Clea~_ninct 28. TYPE OF ABATEMENT (Check ail appropriate boxes) ❑ Removal 0 Enclosure ❑ Encapsulation 0 Repair 0 Clean up 29. ABATEMENT PROCEDURE (Check all appropriate. boxes) ❑ Full Containment ❑ Otovebag El Tent 0 DEP Variance Application 30. LOCATIONS OF ABATEMENT DESCRIBE SECTION AFFECTED SURFACES Floors) OF FLOOR AMOUNT OF ACM DESC I ION OF WORK BEING '? (e.g. entire. east wing, room #, CONTAINING ACM (e.g. Pipe tagging, caring, plenum J SQUARE PERFORMED ._._._tecu~,~n;,«..,N ►M~..,_._._..

2nd PH ducts,

indows tanks, dedcin . etc FEET UNEAR FEET (e'g' Nnning cable. insta and bi etc- 120 Scope B Cleaning

31. 1 hereby declare that the information provided herein is true and complete to the best of my State and NYC laws and regulations applicable to knowledge. I am familiar with Federal, asbestos related work.

ATC Associates I1.c _ rio / t Name of Air $ cos toval Trio AsbestQ Remo • 1 dl of Asb a ontractor Print Nani ,

j ca er than Owner)

Signature Signature Signature 11~~13 I / Date 32. c-c. the work specified herein. have authorized the Emily Sorkin Print Name of Owner C~ 1 Zt a3 Signature - D e A STAMPED COPY OF THIS FORM INCLUDING AMEND ENTS MUST BE AVAILABLE AT THE WORK SITE. Arty modification of information provided on this form must be reported immediateli itinq directly to the NYC DEP ACP. The requirements " rol Program Rules may not be lawfully avoided or of work in incremental nr ACP7 V2001

NYC-WTC 000129017