Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

El t 4Lu siç.°'°°"\ NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program ' J9''tf*Junction Boulevard. 8 Floor. Corona, NY 11368-5107 ' i 91 ~(~

Dz.P ASBESTOS PROJECT NOTIFICATION I Building Or T U No fOR OfflCUhl USE ONLY

JTTEN f pc ORMS WILL BE "~"`"" (ASBESTOS INSPECTION REPORT) I. 7 ACCEPTED :..• ~ --• -!` '• r. (S fee 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 Q /~ f~ n A 2. Address P CI CL- S I 1- i Borough k' Zip

AKA 1-a 5 C ff U - C4 STMT 3. Block g $ 4. Lot 1

U (Z C_ 6. Name of Building GN u(2.0 H OF S 5. Type of Facility—CJ II. BUILDING OWNER

7. Name k gr_" I C)CES~ 0 N£LZ " " ( 't • • 8. Contact Person EA? H- .Z M Ab 1r,444 ____ ___ Fax # ~ 10. Address v'C S a S ~-~ _ City---1~1 ' State Zip oOI Ill. GENERAL CONTRACTOR

11. Name _______ -- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ~J C .1z'o __ ------ —13. Contact Person f 14. Federal Employer I0. # _._._._._._._,_. P11 15. Tel. # J`16' _ ~~~-3 — 000 Fax #_---- 51 ?dl,345 _._._._. Zip 1(Z 16. Address —City J ~/ - State /U

V. THIRD PARTY AIRMONITOR

17. Name v ) ~ y_ '2 IG"~ PC 18. Contact Person _ ± J_ '

19. Federal Employer I0. # _ 20. Tel. # a _ DQ~1— Fax # 2Ia -,9 _2 06 21. Address { -- City ~ -'G — State tL_ Zip J00 ( .

23. NYS DOH ELAP # - (I SL -tJ 22. Sample Analysis Laboratory— C( ! /~!L ~3 a G~ = '1-CS c

VI. PROJECT INFORMATION Dy 24. Starting date for this portion of work _ 3O 02 Projected completion date 30

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

Shift from: _ ❑ am ❑ pm to ❑ am ❑ pm

If other, specify

I Access to inspect the premises must be provided during the work schedule indicated in this item. I

25. Total amount of asbestos-containing material to be abated during this work

•- 1 0 Square Feet, and/or Linear Feet t6 ACP 2/200

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NYC-WTC 000111086