NYC 9/11 Public Portal Document
NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
A`~ Asbestos Control Program
y D r■1 58-17 Junc," Boulevard. 6' Floor. Corona. NY 11368-5107
Su"ding Dept or TRU No
ONLY FOR OFFICIAL USE ONLY
ASBESTOS PROJECT NOTIFICATION
(ASBESTOS INSPECTION REPORT) 1. C
csek fee sehedule)
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.
L FACILITY
2. Addresss l 1.3 IL$. (y 1Q T Borough Zip L 3-eTfl
AKA 3. Block 4. Lot
5. Type of Facility 6. Name of Building
II. BUILDING OWNER
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7. Name ~ X, 1`3-9
, -9 1C&" L --c 8. Contact Person d', ,, P -t~4 tI .
,.iei.# \1ct cg~a Fax 7~;~'?Sg`
10. Address '3'T. P City State " Zip p `-
Ill. GENERAL CONTRACTOR
11. Name Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name -, eJl. O 13. Contact Person 7 ) Cam
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14. Federal Employer ID. # P11 15. Tel. # $ 16 - 7~I -3 ~ O Fax # 5 6__ l ?1 5
1b. Address 3o/b L" L' City kJ171V7 State Zip II? ?r
V. THIRD PARTY Al MONITOR
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17. Name 18. Contact Person I%(iC:i4-E _ t..(oL# -.t .
19. Federal Employer ID. #____________ 20. Tel. # a 13
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9 Fax # ..2J 9 2` 2 - O(o -j D
21. Address VP e LASf ff l * S ( f ( City .F , 2#. State Zip (°°(
/ ~wT]]''
22. Sample Analysis Laboratory SClfi41'4 (C_. 23. NYS DOH ELAP # (/~ £9,C .
Vt. PROJECT INFORMATION
24.Starting date for this portion of work I7h' 0 a Projected completion date
Asbestos work schedule D Monday D Tuesday D Wednesday D Thursday D Friday D Saturday ❑ Sunday
Shift from Dam ❑ pm to _El am D pm
Hother,
specify
Access to Inspect the premises must be provided during the work schedule indicated in this Rem.
25. Total amount of asbestos-containing material to be abated during this work
t>o Square Feet, and/or Linear Feet
1
r.~•••:s c:c:a t
I',',
NYC-WTC 000100461
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