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, 8th Floor. Corona, NY 11368-5107 or TRU Ni USE ONLY ASBESTOS PROJECT NOTIFICATION (ASBESTOS INSPECTION REPORT) EPTED "_rs.tOa44r,

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 n ~' 2. Address _~1— ~-+~1i QS S T1 T Borough Zip I OO O

AKA O2j_ V 3. Block E 4. Lot ~Q

5. Type of Facility 6. Name of Building

II. BUILDING OWNER ~m E 1 f ( Cb t ~—'L'' 8. Contact Person f=U-e-N AC A4 7. Name —

9. Tel.#~ ~q 1 "tv~ ~"~- J _~ ~1 Fax# -) a33 -3 ~~ 10. Address 1Pt C -- S L k City __1 State tL~ _ Zip _ O 00

III. GENERAL CONTRACTOR

11. Name_ ----- — Tel. # — --

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ~ em u" ------- _. ._13. Contact Person _____

14. Federal Employer ID. # ._._,_._._._._._ P 11 - Tel. # J i 6 _ )5. ,_53~6 0 Fax # _ JI _=?~i _ 7, 16. Address ~ !>I 1e -- -- City / L _State /V Zip _([? '3_

V. THIRD PARTY AIR MONITOR

17. Name ---- C~ 2 kM ZE2 G ~' S PC ------+--18 .ContactPerson Ih'ltc~+~rEi_ t"~t ----- 19. Federal Employer ID. #..__......_... ._— 20. Tel. # a r3=~aa - OOJ Fax # zl cLL c —063 0 21. Address ~~ g -1 City ' ~ State ~ Zip _ OO 'f

22. Sample Analysis Laboratory— S 'c.L (17 —J rofteS v" 23. NYS DOH ELAP #_JJ i1 gd

VI. PROJECT INFORMATION 24.. Starting date for this portion of work _ dd- Projected completion date

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday 0 Friday 0 Saturda~ Sunday

Shift from: __ ❑ am ❑ pm to ❑ am ❑ pm

/ If other, specify --- — —_—_ O Rip \ Access to inspect the premises must be provided during the work schedule indicated in this item. ]( itn JUL 3 0 2002 v JJ 25. Total amount of asbestos-containing material to be abated during this work -2 Square Feet. and/or Linear Feet

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NYC-WTC 000111088