NYC-WTC_000204596

NYC 9/11 Public Portal Document

NEW YORK CiTY BOARD OF EDUCATION GENERAL FIE! D VERIFICATION FORM

MAME OF THE CONSULTING FIRM. 4 i C Associates Inc. SPECIFICATION NO

SCHOOl S CA T W IAA ADDRESS: SV hJ Y 1g c . '

TYPE OF SERVICES PROVIDED: (check as applicable)

□ ASBESTOS TECHNICIAN □ PROJECT DESIGNER* KJmisc. consulting services Q air SAMPLING TECHNICIAN □ PROJECT MONITOR

LOCATIONS(S) WORK PERFORMED SeVV\* A 6 ^3 A

DATE .NAME OF THE NAME & SIGNATURE jSf ^/INAFS OUT PROFESSIONAL OF AUTHORIZED PERSONNEL CUSTODIAN/PRINGIPAL

r name (print) signature name (print) signature /M*’' 1^" wEz

Q NOTE; Please complete the following as applicable, indicate "N/A” if not applicable. - H l"^ Asbestos Inspector's no of school visits

So Ail Sain|.iling Technician's no, of school visits: I—i o 'Minimum payment for Pioject l.lesiynei's services shall Ire four (4) limes the unil piice |)ei horn. o I Project Moniloi's total no of hours: o o co o OA Mise, consulting services no. of hours: 1 co CO CO

NYC-WTC_000204596