NYC 9/11 Public Portal Document
`~ " NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
Asbestos Control Program
59.17 Junction Boulevard. e°' Floor. Corona, NY 113684107
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ASBESTOS PROJECT NOTIFICATION
(ASBESTOS INSPECTION REPORT)
1.
When submitting this form at the NYC Department of Buildings. the original loan
and three (3) copies with original
signatures are required. Submittal at the NYCDEP requires one copy of the form with original signatures.
form must be submitted to the NYC DEP not less than one week in advance of the start of This
abatement activities.
1. FACILITY
2-Address )Q~~ES I p~20A,-b W ~ 1 ( Borough N` 1 Zip t o o 07 —
AKA 2 S- a'y _'n b.) tc 3. Block 4. Lot
5. Type of Facility 6. Name of Building
II. BUILDING OWNER
7. Name __C -L& ' 8. Contact Person
9. Tel. # 17 f ____ Fax #
10. Address S 1' /v `
City State p /00
Ill. GENERAL CONTRACTOR
11. Name _
Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name _ €.L GY?J 11'O
—_-- 13. Contact Person O~ (~~
_._._._._._.-
14. Federal Employer ID. # PII...... C
15. Tel. # J
f~ e ?d
... - V 'c3~OO Fax # c )~_
16. Address 0&)s_— City .J /(u/ /f4 State N Zip I0-
V. THIRD PARTY AIR MONITOR
1 A `r
17. Name ~ Qd9 kr(ZECL ~, r pC 18. Contact Person alt L 4 O (—&
19. Federal Employer ID. # 20. Tel. # a «_a - 00 L. Fax# 2L _'2a -O6 3 O
21. Address City t^t ~~J G~?l~ OO
State ~ Zip
/
22. Sample Analysis Laboratory Sc(~c( (F(L I A7gC A rr(E$ try 23. NYS OOH ELAP # if cfg-(.?
VI. PROJECT INFORMATION
24_ Starting date for this portion of work (p 'I/C) o . Projected completion date 7 (30 O~
Asbestos work schedule ❑ Monday ❑ Tuesday O Wednesday O Thursday O Friday ❑
Saturday 0_ Sunday
Shift from: ❑ am ❑ pm to ❑ am 0 pm
If other, t:...
,- `\.
specify ' r.
Access to inspect the premises must be provided during the work schedule
indicated in this item.
25. Total amount of asbestos-containing material to be abated during this
work
_ \.. % _/
Square Feet, and/or Linear Feet . 1 ="
t:.c ?11001
tSdiaJSC'.i~RC4~7
tru 7
NYC-WTC 000109848
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