NYC 9/11 Public Portal Document
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NEW YORK STATE DEPARTMENT OF STATE
OFFICE OF FIRE PREVENTION AND CONTROL 6)
1^11 HAZARDOUS MATERIALS REPORT FORM
(General Municipal Law, § 209-u)
The information entered herein is essential to your local fire chief for the protection of your employees, the fire
fighters and citizens in the immediate area, and to reduce damage to your property in the event of a fire or an
emergency.
Every fire insurance policyholder, engaged in commerce in this state, is required by law to report the presence of
hazardous materials at their business address.
Failure to file in accordance with the provisions of section 209-u of the General Municipal Law could result in a
fine.
A separate report is required annually for each business address.
WHEN COMPLETED, THIS FORM MUST BE SENT TO YOUR LOCAL FIRE DEPARTMENT.
Hazardous Materials Location*
Salomon Brothers Inc Same
Firm Name Street Add. Only
Seven World Trade Center N/A
Bus. Add. Bldg. Name or No.
New York, New York 10048 N/A
City, State, Zip ______________________________ City, State, Zip
(212) 783-7000 July 1
Tel. No. Policy Anniv. Date
Nameof Jack Glass (212) 783-6252 (617) 641-2487
Emergency Contact Bus. Tel. _______________ Home Tel. ______________
(Signature and Title of Person Completing Form)
*lt is suggested that a separate form be filled out for each building that contains hazardous materials.
EXEMPTIONS
Requests for exemptions from this law must be made in writing, attached to this form, and filed annually with
your local fire department not later than the anniversary date of your policy.
All exemptions approved shall expire on the next policy anniversary date.
Exemptions denied shall require that the insured file a completed hazardous materials report form within 15 days
of denial.
FOR FIRE DEPARTMENT USE ONLY
Exemptions: Approved Denied Additional Information Needed
(Date) (Signature of Fire Chief)
(Fire Department Name and Address) (Print Name of Fire Chief)
DOS-347
New York State Department of State, Office of Fire Prevention and Control
NYC-WTC_000169133
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