NYC 9/11 Public Portal Document
NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
Asbestos Control Program
59-17 Junction Boulevard. 8"' Floor, Corona. NY 11368-5107
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FOR OFFICIAL. USE ONLY
PEWRITTEN ASBESTOS PROJECT NOTIFICATION
FORMS WILL BE - (ASBESTOS INSPECTION REPORT) 1.
ACCEPTED ! :!?$:!. 1d! . 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.
1. FACILITY
,w~ 44
2. Address S t.l.~r r S r ~-~-~ Borough !y Zip b ©~
AKA 3. Block L3 4. Lot 1 t_
5. Type of Facility 6. Name of Building
11. BUILDING OWNER
7. Name S M.JL s r LLC- . • '8. Contact Person
9. Tel.# t 4%ra U Fax#
`
10. Address 5 L"" , City________________ State Imo' ip __( o t
III. GENERAL CONTRACTOR
11'Name ^— Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name ,J E'i~ c 1'C 13. Contact Person 7cc ...)y'
14. Federal Employer ID.#!------------ P 11 -15. Tel. # 516 - 71,300p Fax # I' / d
—~ 3d85
/
16. Address _01 C~ ' Vt City ) f State Zip _II? ?
V. THIRD PARTY AIR MONITOR
17. Name ~ _I 2 kit -E P_ ,~1G t S PC 18. Contact Person Ilt t 4 L t`(°L. /M( .
19. Federal Employer ID. # 20. Tel. # a (o - ' 9 2 - 00 Z Fax # 2Ja - 0 3O - ?2
,`
21. Address pf c2 g 1 ~ 'D2E7 City rV'€1'J t~ State Zip (00
/
22. Sample Analysis Laboratory S .(f~f17 R - 1 ~ ! /£S _ 23. NYS DOH ELAP #_-
Vi. PROJECT INFORMATION I
24.Starting date for this portion of work I Projected completion date IZ o Z
Asbestos work schedule ❑ Monday ❑ Tuesday 0 Wednesday ❑ Thursday ❑ Friday ❑
Shift from: ❑ am ❑ pm to ❑ am ❑ pm ,/
If other,
specify
Access to inspect the premises must be provided during the work schedule indicated in this item. JUN 282#0
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25. Total amount of asbestos-containing material to be abated during this work `~ OGSJLE.
° r2u
.To0 Square Feet, and/or Linear Feet n,
r M-i °r r' •
RR ' ? t7@
bEA7
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NYC-WTC 000100408
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