Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION El 13 L(J j c Asbestos Control Program 59-17 Junction Boulevard, 6' Floor. Corona, NY 11368-5107 Building r or RU No 62- FOR OFFIOIAL USE ONLY ASBESTOS PROJECT NOTIFICATION (ASBESTOS INSPECTION REPORT) tee 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.

I. FACILITY ,, S I L ET OO O 2. Address _tom CL Borough t v '1 Zip

AKA I Gr f Few '•i2L1{ eEC.i o~ l 3. Block g~ 4. Lot a -

5. Type of Facility 6. Name of Building

II. BUILDING OWNER

7. Name Cµ tC CAS O) OeO _.. : 8. Contact Person ! 4F MA C4Prt

9. Tel. # 3~ Fax # ert 10. Address _ V E SEA 31 City 1L_A State IJ'_ Zip

III. GENERAL CONTRACTOR

11. Name _______ -- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name `-~~""' —._._._._ _------13. Contact Person ~ _____

14. Federal Employer ID. # _._._._._._._._._P1 _._._._._._._. __15. Tel. # c11L"_ 7L 30 O Fax # c~I I d~S 0 State L 4 zip _L2ç:.3 _ 16. Address QLc . 2 _ _City L'744---- V. THIRD PARTY AIRMONITOR ~r 17. Name j v ))2 `' f _ ' Z E0 - & J6 '=' ~ r~jC 18. Contact Person vii4 L 1 ` of"

19. Federal Employer ID. # ___----__ 20. Tel. # a( a - C~O~ Fax # 2.I91 ~a - C 3O ~ City ~=~ =-t i State _zip oo 21. Address ~2 g L 2T ~ { _—

22. Sample Analysis Laboratory— ~l /~!L t^ M c °015 c 23. NYS DOH ELAP #_ ( f

VI. PROJECT INFORMATION O oZ Projected completion date aZ 24- Starting date for this portion of work _ - d

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday 0 Friday 0 Saturday 0 Sunday

Shift from: ❑ am ❑ pm to ❑ am 0 pm

If other, cp specify —__ — — _---

to inspect the premises must be provided during the work schedule indicated in this item. I( JU L 3 0 200 2001

25. Total amount of asbestos-containing material to be abated during this work 3 1 ~3I _ Square Feet. and/or Linear Feet ACP: 2!200

PfiC~A;,tr I I

NYC-WTC 000111084