NYC 9/11 Public Portal Document
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(p7 (.L "(C- NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
- Asbestos Control Program
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4. 17 Junction Boulevard. 8" Floor. Corona. NY 11368-5107 t.Q/Hiip
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Et -* ASBESTOS PROJECT NOTIFICATION Building Dept. orTRU No)
FOR OFFICUL USE ONLY
BE "-' (ASBESTOS INSPECTION REPORT) 1.
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
2. Address t.v"c Borough N * Zip _ I OOd'
AKA 3. Block 4. Lot
5. Type of Facility 6. Name of Building
IL BUILDING OWNER
A An
7. Name V~ Sc7,. c -r~.,r-~ $ c ic& LL _ . Contact Person 1\U ' n At
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9. Tel. # 'V
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t5PFax_
10. Address 3'1 s'~ A y u City_) ' _ State ' A Zip tO t S
Ill. GENERAL CONTRACTOR
11. Name Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name - f ` €'€ C tO [ 13. Contact Person C ~~
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14. Federal Employer ID. #L J ' 1I 15. Tel. # cJ 16 - 7i3°" 0 Fax # sl — ?d / 3 5
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16. Address S~bQ~?L~ - ]
City ~/!~f State Zip 1/2 7?_
V. THIRD PARTY AI MONITOR
17. Name_CAJ R S. T
A ~~ NG r ~ S . hh
`C 18. Contact Person £L.
19. Federal Employer ID. # 20. Tel. # a 12 - 91912- O0 Fax # 2L — -Ob 3 O
21. Address g frS1 q (t?Eff7 City l~t-rp —rcr— ~ State ( Zip oo t
22. Sample Analysis Laboratory SL' t T(Fl L A s11 23. NYS DOH FLAP #_(1' g - 0
VI. PROJECT INFORMATION ,
24_ Starting date for this portion of work_9\ Projected completion date Y
Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday CI Friday ❑ Saturday D-Suttday
Shift from: 0 am 0 pm to D am ❑ pm Y
'
ter^
If other.
specify ' RECEIVED
Access to inspect the premises must be provided during the work schedule indicated iii Vvss Rem. SEP 20 20(12
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25. Total amount of asbestos-containing material to be abated during this work
Square Feet, andlor Unear Feet
ACP7
212001
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NYC-WTC 000100475
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