Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard. 8" Floor. Corona, NY 11368-5107 Rl.~1~02M Building Dept. or TRU No FOR OFFICIAL USE ONLY ASBESTOS PROJECT NOTIFICATION (ASBESTOS INSPECTION REPORT) 1. L e ACCEPTED —_' (See se schedule) 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.

1. FACILITY

2. Address 150 15 2 G} I- VI g -1? .S ST$-T Borough _\3' Zip _0 __ AKA 3. Block t3 I 4. Lot S"

5. Type of Facility 6. Name of Building II. BUILDING OWNER

7. Name I '" I ~ C Wa t'VIO ~s (LS S C bb M) f11U w W. Contact Person u s. , L

9. Tel. # Fax #

10. Address ~-- ~t✓ tJ1~tsl ms e~_ ST City &~~' L'I State Zip It /

Ill. GENERAL CONTRACTOR

11. Name Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name rQ elL c~a` ' ICJ ( 13. Contact Person______ Cam_ _

14. Federal Employer ID. #J P II 15. Tel. # cJ / - 7t I -30O O Fax # JI'p / cJ/ 3"D S 1 1f? f'.. ,`` 16. Address ~ i] ~~-1 C~ r y ~' City -- /~+' State____ Zip

V. THIRD PARTY AIR MONITOR ~j 17. Name ~ f G 18. Contact Person Allci+,rEL N(° t-. Atr. ~ ZE f 19. Federal Employer ID. # 20. TeI. # 2(3 - as - 0 Fax # z!a . 22 -O6 3 0 21. Address J2P g 1 5'(EE 7 City /Y'G1' ) TE7= - tom State t'-( Zip oO / 22. Sample Analysis Laboratory !alte4i71!L I.. i t DWI crc 23. NYS DOH ELAP # (r'S~ ~Q

VI. PROJECT INFORMATION 24. Starting date for this portion of work I p— Projected completion date 3 Asbestos work schedule 0 Monday 0 Tuesday 0 Wednesday ❑ Thursday 0 Friday ❑ Saturday 0 Sunday

Shift from: ❑ am 0 pm to 0 am 0 pm

If other, specify )J RE auEa \\\ Access to inspect the promises must be provided during the work schedu)e Indicated in this item. a° JiJ t 3 1 2002 25. Total amount of asbestos-containing material to be abated during this work 3~STOSILEF:'' . i RORGRAM Square Feet, and/or Linear Feet

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