Shipping order form for DEP materials, October 2002

NYC 9/11 Public Portal Document

,~~ urr orna yp~ir..... NYC t EP~ARTWENT OF ENVIRONMENTAL PROTECTION asbestos Control Program 59-17 Junction Boulevard, 8th Floo.. Corona, Y 11368-5107 I

t* PEWRITTEN ~'Ro FORMS WILL BE ACCEPTED Nraivf . WW. yg.Se:Jaer.. ASBESTOS PROJECT NOTIFICATION (ASBESTOS INSPECTION REPORT) Building Dept. or TRU NO.. FOR OFFICIAL USE ONLY

1 ' V.LI,-& fee 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 18 ,SON N S -Mei~T M Arty Borough Zip -(0038 AKA IS MAi OEN LA tJ E ZZ JON M STr E 3. Block 65 4. Lot T .5. Type of Facility___ .Ø*A M E1 . c. A- L 6. Name of Building II. BUILDING OWNER

7. Name RELJiQE=_ RALTY? % tt LL RROP .RTI S 8. Contact Person AwizeNCE A06 9. Tel. # (212) 233-- 26og Fax # 10. Address _ t5 " t DE N LA NN E — City N~uls 't' O R u State _ N _ Zip i 0038 III. GENERAL CONTRACTOR

11. Name_-- ---------~-- Tel. # --~-- IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name t3E.NJAM t t1 Icer tZZBAw 4 S ON —T! ___13. Contact Person _ t A NN C O

14. Federal Employer ID. #1,_._._._._._._._._.PI 15. Tel. # C118) 53 t12900 —

16. Address 1241_ QAL_ Pt4 AV eNV E ------- City 3 ROOK L1i IJ ---- State jL.. Zip t OO t L_ . V. THIRD PARTY AIR MONITOR

17. Name ttJARi?EA►_ F01 z EhtG iNEE S _-18. Contact Person N'RN 19. Federal Employer ID. # P11 20. Tel. # Fax # C2t2) g22 - o63cs 21. Address _228 EA ST AS TF4 S'c t -r e- — City Nctu `t'2 -__ State Nom_ Zip _►oO tT 22. Sample Analysis Laboratory — -- 23. NYS DOH ELAP # VI. PROJECT INFORMATION 24.. Starting date for this portion of work 10103 _ 02. Projected completion date I O 131t O2

Asbestos work schedule ® Monday ® Tuesday 19 Wednesday fRI- Thursday ® Friday ® Saturctay..®-Suj day

Shift from: - $°a ® am ❑ pm to 8c ❑ am ® pm If other, 'y specify —_—_- 'CE'v Access to inspect the premises must be provided during the work schedule indicated in this item. OCT q J ar ' [ i 25. Total amount of asbestos-containing material to be abated during this work + d , — (0561T Square Feet, and/or a Linear Feet t ~' f ACP 7 2/2001 E"•"''Stl pf ~Npgn'ik'gr

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NYC-WTC 000101953