NYC 9/11 Public Portal Document
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NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
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Asl?whoa C9ntrol Program
t>1r 59-17 Junction Boulevard. 8 Floor. Corona, NY 113685107
-
ONLY DEP JUNO4
FOR OFFICYLL. USE ONLY
TYPEWRITTEN ASBESTOS PROJECT NOTIFICATION
FORMS WILL BE r"""0~ (ASBESTOS INSPECTION REPORT) 1. ~C
ACCEPTED .!!!!! ;t..~,
(s'$e feectiedate)
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 1' S Borough _t'' Zlp L c Oa r
AKA 3. Block 4. Lot
5. Type of Facility 6. Name of Building
It. BUILDING OWNER
( A
7. Name C2 0 c 1 V1DRL L \ &C t .L G . ' 8. Contact Person M~
9. Tel. # Fax #
10. Address ~-~ City l State Zip _L t
III. GENERAL CONTRACTOR
11. Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name 3E'eL. C' )1it4 13. Contact Person _/C?-) tom
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14. Federal EmPtoYer 10. # [ P11
._._._._._._._115. Ta1. # c~ . 7ti_-300 0 Fax # 3!
3 5
dd
16. Address 3 J )OS/ City fi ~1 State Zip. 1/? ~i?
V. THIRD PARTY Al MONITOR
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17. Name t+' V i4Z12.. G r S, Pc 18. Contact Person ntt L.
19. Federal Employer ID. #____________ 20. Tel. # 9 ooh- Fax /I .2.1? -- - 06 3D
21. Address t 7t g *!K l (EEF 7 City 9 -k Tt?=~IIC State t 4 Zip 0
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22. Sample Analysis Laboratory S~ FE 7«h
r~ - a fES u c 23. NYS DOH EtAP #_(1 g -C.
PROJECT INFORMATION
24.Starting date for this portion of work O C.L Projected completion date ~~---
Asbestos work schedule ❑ Monday Q Tuesday ❑ Wednesday ❑ Thursday 0 Friday ❑ Saturday ❑ Sunday
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Shift from: 0 am ❑ pm to 0 am CI pm y, 6
If other, *
specify
M LLtFJ'r_D
Access to Inspect the premises must be provided during the work schedule Indicated In this Item. J1t, L 3 1
2002
`t~fsasS
25. Total amount of asbestos-containing material to be abated during this work aLEh~o .
P
Square Feet, and/or Linear Feet TORJJG
ACP 7
212001
CJ?£AlorE.p~% ,
* o::'•ls C.:dT9
r~cca~ra
IFII
NYC-WTC 000100490
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