Asbestos project notification and inspection report form

NYC 9/11 Public Document Portalal i S I 's al•ooa NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION • D r Asbestos Control Program Junction Boulevard. V Floor. Colon . NY 11368- 91-17 Junon suiIQing Oept. or TRU No ry FOR OFFICIAL USE ONLY kiTTEN ' °' ASBESTOS'PRO.JECT NOTIFICATION 4s S w~LL BE ' (ASBESTOS INSPECTION REPORT) 1. ` ► ' +A CCEPTED —• i~ i•~•ee. Qa,~• When submitting this form at the NYC Department of Buildings, fhh 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 Tess than one week in advance of the start of abatement activities .

1. FACILITY

2. Address I Lit L..1,1A -y i S 2€_ 1 Borough zip to o3&

AKA 3. Block 4. Lot ._ ,

5. Type of Faclity 6. Name of Building IL BUILDING OWNER

7. Name W l Lw pr►n S S.S tC t F> (S-S - a. Contact Person

9. Tel. #. Fax # U fl, City N zip << 0 t 10. Address I -80 111. GENERAL CONTRACTOR 11. Name Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name I3E1€ (,:r,* 1zO ( 13. Contact Person _7 :i ' C ` —

14. Federal Employer ID. €._._._.__._._._._._. !II 5. Tel. # c116- 75-( -3c -300 ° Fax # s1 - ;W_3 6 6 15 ( 16. Address OJb )C) 1OS ,'?e City State A)'( Zip II?

V. THIRD PARTY AIR MONITOR j)kT4zEz2 Gr nlle:l}*EL ff 0 L.Arl . 17. Name R8..f L 'k'S. Pc 18. Contact Person

19. Federal Employer ID. #_____________ 20. Tel. # a f P - 9aa - Fax# 2Ja - 92a -Ob 3 O

21. Address g TIESf 4(.S * S'i-fE7 City f~' 1~ State Zip 0 ) 22. Sample Analysis Laboratory SG( i t tC— __g_____23. NYS DOH ELAP # (f' g -C

VI. PROJECT INFORMATION

24. Starting date for this portion of work 0) .- Projected completion date UY 10114

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday 0 Friday ❑ Saturday ❑ Sund,

Shift from: ❑ am ❑ pm to 13 am ❑ pm

If specify n~ 'ECE VEd Access to Inspect me premises must be provided during the work schedule Indicated in Nrs 1em 1( I 1.

I SEP Iii 11 ?O ~~{ war 25. Total amount of asbestos-0orttaining material to be abated during this work 44 o Square Feet. and/or Linear Feet \\ f IZ~ 1 ACP7 '1/2001 t Ki i r f t;awti.Fp•Ju "'JS C:;Q SrAT IJC'p.IJ IOiry

NYC-WTC 000110381