Asbestos project notification form, NYC DEP

NYC 9/11 Public Portal Document

( W1r ofP4p7 ql NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program ~J r'~~ °• MGM 59-17 Junction Boulevard, 8°i Floor, Corona, NY 11368-5107 Bui ding D t. c TRU No ONLY FOR OFFICIAL USE ONLY ~e TYPEWI F R y y~

~'O'Mtaraipa° ° ASBESTOS PROJECT NOTIFICATION ' (ASBESTOS INSPECTION REPORT) w .nYC.IIov/d

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. 4 APCi. FACILITY 2. Address 20 JOW N S-rttEET _ Borough MAN Zip 10038

AKA --- ------ —_ 3. Block S — 4. Lot 7. 2 _

5. Type of Facility_--- — — 6. Name of Building II. BUILDING OWNER

7. Name CE ~t tUR PeAL'rY -- ~ ---v 8. Contact Person Y _---

9. Tel. # C2?t ) 26T- 7YT8 --- Fax # —~-

10. Address!------- --- -- -- PII —_W _-- - - ----City--- L PPII .-. ~ State_PII—;_Zip_/.-. P11

III. GENERAL CONTRACTOR

11. Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name S AM 1J ~tt)RZgAN Sc~N C'ou_rP-oL IMC 13.ContactPerson Lou'G_ IANNiCA ---

14. Federal Employer ID. # P11.- 15. Tel. # t1 Fax # ~ -s! ) 2 E - ' 2 —_

16. Address I ZA S ¢sa".P9 AV ue --- City __ BR-C'0 WAN r4 `_ State N± Zip _11236

V. THIRD PARTY AIR MONITOR

17. Name pRi1zVV- E Nr- I MEm-P 5 —_--18. Contact Person _tAt W AQL _t N —~-

19. Federal Employer ID. #_ _ 20. Tel # (2I2)g?2-oo_r7 Fax# _2tz) 922 063°

21. Address _ 9-28 EAST ASrC Sr¢~~'r _— City— blew Yogic --` State L _ Zip (0O IT —_

r 22. Sample Analysis Laboratory---__— -- --- 23. NYS DOH ELAP #

VI. PROJECT INFORMATION 24. Starting date for this portion of work _ 10 oS (02 _ Projected completion date l0 131 102 —

Asbestos work schedule 54 Monday ®. Tuesday ® Wednesday ® Thursday I Friday ® Saturdgy_.® Sunday —gt~ Shift from: ®am ❑ pm to_~—❑ am ®pm L* +

l 1 , specify ------------------- --------- Access to inspect the premises must be provided during the work schedule indicated in this item. i (,! 1 ~~y~o 2

-u auArn f 4 j 25. Total amount of asbestos-containing material to be abated during this work `:` ~ ef' 5 6 'I S — Square Feet, and/or —_ a — Linear Feet > V ACP 7 212001

NYC-WTC 000094344