NYC 9/11 Public Portal Document
' NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
1 D A r
Asbestos Control Program
dnctlon Boulevard. 8°i Floor. Corona, NY 11368-51 1 Building Oe or TRU No
ONLY FOR OFFICIAL USE ONLY
'( ASBESTOS PROJECT NOTIFICATION
(ASBESTOS INSPECTION REPORT) 1.
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 1T L C t` i rwl I -eS -5 SET Borough N ' Zip _ I
AKA 3. Block I 4. Lot
5. Type of Facility 6. Name of Building
II. BUILDING OWNER
7. Name ( ' AI- 12 k P J-1-1I -!'.1 ,e, G W,44-\ • ' 8. Contact Person
9. Tel. Fax #
10. Address J ~ 2SL City N ' I State Zip U000
III. GENERAL CONTRACTOR
11. Name TeI. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name J 1B e) p l 13. Contact Person 4-1o8 /9
14. Federal Employer ID. # PII X115. Tel. # J` 1' - 7cf -340 0 Fax # — 5i / , 3 5
16. Address Q1C7&', / — City l J 1T 1 /4 State /i ( Zip I 1? c?
V. THIRD PARTY AIR MONITOR
, r
17. Name V \J 4ZE2.. -jJ6i'4 = J S PC 18. Contact Person l 4 L
19. Federal Employer ID. # 20. Tel. # ai3 - 9aa - 00j Fax # 2J3 - V P -O6 3O
21. Address . A 1, I e 7 City State____Zip 00
22. Sample Analysis Ctf1-(7lF(L ll. *6t 744 /E$, t fC. 23. NYS DOH ELAP #
VI. PROJECT INI'DRMATION
24_Starting date for this portion of work O Projected completion date /4 0
Asbestos work schedule ❑ Monday 0 Tuesday ❑ Wednesday ❑ Thursday 0 Friday ❑ Saturday 0 Sunday
Shift from: ❑ am 0 pm to ❑ am 0 pm
If other,
specify
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
3 Square Feet, and/or Linear Feet
ACP 7
E~'a...t.ir~i
V2001
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NYC-WTC 000111077
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