NYC 9/11 Public Portal Document
NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
Asbestos Control Program
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59-17 Junction Boulevard, 8°' Floor. Corona. NY 11368.5107 35/4a
ONLY D:~.P: ASBESTOS PROJECT NOTIFICATION
Building Dept o
FOR OFFICIAL U
(ASBESTOS INSPECTION REPORT) 1.
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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
2. Address (OS J j Qj rL01 WP 1 Bergh t~ Zip C3 o O
AKA 3. Block 4. Lot
5. Type of Facility 6. Name of Building
U. BUILDING OWNER
7. Name ors &c • • 8. Contact Person ct4s T A't-F~C f
9. Tel. tt~2)t O&Sl) Fax JJ ) )75C
10. Address 37 S? i' -( k- City 1 State N ' Zip 1d t
Ill. GENERAL CONTRACTOR
Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
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12. Name i~ e1~
p ( 13. Contact Person ) tom 14
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14. Federal Em o er ID. # . P11 15. Tel. # 6' 6 - 70 t ^3 0 O o Fax # Jl'P- _?'-3c85
16. Address 30/C7 ILLJS, //e City 41t )t State Zip II? ?
V. THIRD PARTY Alf MONITOR
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17. Name Q T ►[ ZF 2 . jj_, r S . PC 18. Contact Person P%itc# EL ((oLkr4.
19. Federal Employer ID. # 20. Tel. # a( - DO Fax #213 -06 30
21. Address J22 € cf !~J S ( fi r z City l~` t7'=1~ State t. t Zip oc t •
22. Sample Analysis ?1!(ES 23. NYS DOH FLAP #
VI. PROJECT INFORMATION
24. Starting date for this portion of work o_ Projected completion date
Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Friday ❑ Saturday ❑ Sunday
Shift from: El am ❑ pm to 1J am El pm
If other,
specify
(Access to knspect the premises must be provided during the work schedule indicated in this kern.
25. Total amount of asbestos-containing material to be abated during this work
Square Feet, and/or Linear Feet
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NYC-WTC 000100453
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