NYC 9/11 Public Portal Document
NYC DEPARTMENT OF ENWRONMENTAL PROTECTION
Asbestos Control Program
59-17 Junction Boulevard, 8°f Floor, Corona, NY 11368-5107
ONLY#i %
7Y BE aVAL n~
ccF ASBESTOS PROJECT NOTIFICATION
(ASBESTOS INSPECTION REPORT)
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 E QL 3 t ~Q ©A b t PY ( Borough N '` 'r Zip t O o O7 —
AKA .2 >—" -4- 1 ç f Q CL zs( 3. Block 4. Lot
5. Type of Facility 6. Name of Building
II. BUILDING OWNER
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7. Name........................_.U_ N._._._ ._._._._ 8. Contact Person .)e r f to 1.f3 Vt,r t') .
9. Tel. # PII fax #
State ip /00
III. GENERAL CONTRACTOR
11. Name _-- Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
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12. Name , !veal ~~_— ---- —_-13. Contact Person /~) / /9
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14. Federal Employer ID. # ; PII 5 Tel. # c7-- - 2 1-3000 Fax # ----
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16. Address old > 1&e-- — City J lQ ~ _ State L ~, Zip ,1z 7"
V. THiRD PARTY AIR MONITOR
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17. Name @ A74ZE1L ci J . rh C 18. Contact Person Ott L
19. Federal Employer ID. # ________— 20. Tel. # a (~ - a - 00 Fax# 24a - 2; _ 06.3 D
City _ State f -( _ Zip 00 ( .
21. Address 22 1
22. Sample Analysis Laboratory— S'C(£~` ((F« -I a t~K (E it c 23. NYS DOH ELAP # tI g - c2 -
VI. PROJECT INFORMATION
24..Starting date for this portion of work SQ `(V a. _ Projected completion date _ ZO 0
Asbestos work schedule 0 Monday 1 Tuesday 0 Wednesday ❑ Thursday 0 Friday ❑ Saturdal
Shift from: ❑ am ❑ pm to ❑ am ❑ pm
If other, ~ '"' p
specify ----- t cc
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Access to inspect the premises must be provided during the work schedule indicated in this item. f ri ft • 17' 2 .
i ~]n 1
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25. Total amount of asbestos-containing material to be abated during this work
_I DSquare Feet. and/or Linear Feet
ACP
2/2oC
4E."..~L'°'7f`l i E~d•~R(Ft:EA .
IPtI
NYC-WTC 000109773
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