Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program mp 59-17 Junction Boulevard. 8 Floor. Corona. NY 11368.5107 i h oN4 EM EE- ACC Z!& —. ASBESTOS PROJECT NOTIFICATION (ASBESTOS INSPECTION REPORT) i. FOR OFFICW. USE ONLY

(3 C 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 NYCOEP 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 Borough N' I zip 0O T 2.Address_'15

AKA 3. Block 4. Lot

5. Type of Facility 6. Name of Building 1I. BUILDING OWNER ^ r7 ( A 7. Name Cj~ol c(c r( t`t L- l get L L G • ' 8. Contact Person _ t CP

9. Tel. # Fax #

10. Address '7 City N '1 State " Zip _[ "

Ill. GENERAL CONTRACTOR

11. Name Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name etL~`-'_! O_ ._._._._._._ _ 13. Contact Person / -k_ 14. Federal Employer I0. # P11 r II C 16 - 7~~__3 i..1,15. Tel. # c~ O Fax # _5I /& - 3o*S / t ,~ 16. Address ol~ i e City ~.2r .J/ ' /4 State zip______

V. THIRD PARTY AIR MONITOR

17. Name kr(ZE2 6i 4t%~S pC 18. Contact Person #6L 1 r 19. Federal Employer ID. # 20. Tel. # a~3 ' gas- 0 O Fax# 21___3o -~~ , 21. Address JP € E'T_1{ S .l'` - City f` `I-CP T'tg- State (00( f"-(7'_zip J 22. Sample Analysis Laboratory Sefir((F!L h 7~t Sf v c 23. NYS DOH ELAP # (f' ~ 0

VI. PROJECT INFORMATION Q' 24_ Starting date for this portion of work QZ Projected completion date v ~~--

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

Shift from: 0 am ❑ pm to ❑ am ❑ pm

If other. specify ^~ RttEWEO Access to inspect the premises must be provided during the work schedule indicated in this item. juL 3 1 2002 pcPI8ANHM 25. Total amount of asbestos-containing material to be abated during this work ;SSESTOS C) pftodnM 3,3 a- Square Feet, and/or Linear Feet TR70

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NYC-WTC 000111090