Asbestos project notification form for inspection

NYC 9/11 Public Portal Document

/ lL'~ t rr NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION, E oaaler~,,,Ni • tt s Asbestos Control Program 8th 59-17Junction Boulevard, Floor, Corona, NY 11368-5107 Building Dept. or TRU No FOR OFFICIAL USE ONLY ASBESTOS PROJECT NOTIFICATION (ASBESTOS INSPECTION REPORT) 1. ACCEPTED fee schedule)

When submitting this form at the NYC Department of Buildings, the original form and three (3) copies with original signatures are required. Submittal at the NYCDEP requires one copy of the form with original signatures. This form must be submitted to the NYC DEP not less than one week in advance of the start of abatement activities .

I. FACILITY

N T Borough M1N --- Zip 2. Address _LS i___..._____—__-------

AKA ----------------- _---_--_ 3. Block 79 __ 4. Lot ICI

5. Type of Facility.. _ ______ 6. Name of Building — —_— —

II. BUILDING OWNER

7. Name —_--_ 8. Contact Person ------------

9. Tel. # _---__--~---- Fax #

10. Address _----- -— City ------------ State _--- Zip -------

Ill. GENERAL CONTRACTOR

11. Name ---------- Tel. # ---

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _P AJaliN ka;a26lAlN &m. CA ____13. Contact Person _ Lour_ IANNic

—_ 15. Tel. # _ Ci ? 53i - z9 — Fax #_. 14. Federal Employer ID. # PII _A ____

--- i 16. Address _ 1248—t2w -- Cit BPror~•i to —_ State N —Zip _i!!___.

V. THIRD PARTY AIR MONITOR

...18. Contact Person NI t AG _ ---- 17. Name _~+R P_ p~►~+?c-R ip -----------

19. Federal Employer ID. 4. --- -- 20. Tel. # C212)932-c,c_t —__— Fax #S!_ _

2L Gks'r _ 4siU S'REeT ----- City __—~+ _____ State _ NL_ Zip _ j __—_ __ 21. Address

22. Sample Analysis Laboratory____—__ _____-------------- 23. NYS DOH ELAP #

VI. PROJECT INFORMATION Gjf 24.. Starting date for this portion of work S 1~ Z—_ Projected completion date

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday 0 Friday ❑ Saturday ❑ Sunday ~.. C3 l iJ Shift from: __ B — © am ❑ pm to _—$— ❑ am 01 pm \y~ lI /~ / <y f iECF specify — ------------------ ------- t\ ' VED Access to inspect the premises must be provided during the work schedule indicated in this item. ,r C AUU 25. Total amount of asbestos-containing material to be abated during this work —2t 000 — Square Feet, and/or Linear Feet ACP •)eP 2/20(

NYC-WTC 000094219