NYC 9/11 Public Portal Document
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171 NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
Asbestos Control Program
58-17 Junction Boulevard. 8e Floor, Corona, NY 11368-5107
Suftding Dept. or Tlw No
FOR OFFsc t. USE Ota.v
ASBESTOS PROJECT NOTIFICATION
ll1 BE tK (ASBESTOS INSPECTION REPORT)
EPTED :r,« 1.
When submitting this form at the NYC Department of Buildings, the original form and !tree (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
2. Address _ ? pMJ A i N ~ Zip t 0U -
WET Borough
AKA 3. Block 4. Lot
5. Type of Facility 6. Name of Building
II. BUILDING OWNER
7. Name I ^"Y' , t -Lc ' 8. Contact Person M f'
9.Tel.t 0 S Fax#~7)1a b$-
10. Address _5_ _ k -Au r 4 U
—e City 13 State_' Zip tO 1 )-
III. GENERAL CONTRACTOR
11. Name Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12.NameJL3ee 1 0 13. Contact Person 7 C's/,i
14. Federal Employer ID. # ._.-.-.-.-.-.-.- '11 15. Tel. # c7 7y I "3 00 O Fax # ?d3
d c'85
16. Address 3o/C7 &' /?V City_tJth)75# State Zip 117
V. THIRD PARTY Al)2 MONITOR
A l r
17. Name `Re -f VkK ZE2 t i'C
c, ~j 18. Contact Person _4ef& 7
19. Federal Employer ID. # 20. Tel. # _a rah ' oo~ - O0 Fax # .2lc7 - ?'a "0 3 O
,
21. Address 1K( 4S 7&?fE( City _ State 4 zip (00 a
T
22. Sample Analysis Laboratory_S r (7trFi' - I A7g E _ ~w1ES~ (mot o
- 23. NYS DOH ELAP # t' C.
VI. PROJECT INFORMATION
24_ Starting date for this portion of work L y Projected completion date Et b' _
Asbestos work schedule 0 Monday ❑ Tuesday 0 Wednesday D Thursday 0 Friday ❑ Saturday Q Sunday
Shift from: ® am ❑ pm to El am ❑ pm
If other,
specify
Access to inspect the prerrdses must be provided dustup the work schedule indicated in this Rem. I
25. Total amount of asbestos-containing material to be abated during this work
5 tO Square Feet. and/or Linear Feet
ACP7
e"r 20001
irrf t•a+~' 11t
?ts i'd.•;~i~/,7
tpil
NYC-WTC 000100471
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