Asbestos project notification form, Oct 2002

NYC 9111 Public Portal Document

ASBESTOS INSPECTION REPORT (continued)

26. Asbestos Hauler ASBESTOS TRANS. CO. NYS DEC Permit # 1A-371 Tel.# (631) 9245050

Disposal Site(s) IMPERIAL- P.O.47, 11 BOGGS RD., PA. / SOUTHERN ALLEGHANIES- VALLEYVIEW DR., PA.

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) 0 Sprinkler Replacement d) 0 Renovation/Alteration e) ❑ Fireproofing Replacement f) 0 Other (Describe) _ _

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

29. ABATEMENT PROCEDURE (Check all appropriate boxes) ❑ Full Containment ❑ Glovebag ❑ Tent ❑ 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 #, (e.g. Pipe lagging, ceiling, plenum SQUARE UNEAR (e.g. running cable, installing fire sprinklers, boiler room, lobby, etc) ducts, storage tanks, decking, etc.) FEET FAT removing and replang boilers, etc.)

ROOF • MAIN ROOF ASPHALT, DUCT, DUNNAC 6,812 ITEM #3

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.

WARREN & PANZER ENG., P.C. TRIO ASBESTOS REMOVAL STEVEN PARMIGIANI Print Name of Air Monitor Print Name of Asbestos Contractor Print Name of Applicant (if other than Owner)

1) Signature 64s- ?ate----- Signature 64-- 9 = gnature

//--- t -oz-- _ Date Date Date

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 who is completely Independent of all parties involved in the asbestos project. I hereby declare that I have authorized the filing of this notification for the work specified herein. n n WC X? _ _ f I2 OL Print Name of Owner /~"~ Signatu Date

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

hnv 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. 20O1

NYC-WTC 000134036