Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

Tcrtr ar4ar~,rN, NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION (i i 60&4 Asbestos Control Program 59-17 Junction Boulevard. 8°i Floor. Corona, NY 11368-5107 Olt DAP ASBESTOS PROJECT NOTIFICATION L_ Building Dept. or T No FOR OFFICIAL USE ONLY

~O^"wr"r~iriio~`cc°~ L BE (ASBESTOS INSPECTION REPORT) 1. CEPTED •:^rc.ya:/e<r. 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

2. Address -~I--+~r~'\-- — — 12 ~L----- Borough Iv' Zip i2 iL- AKA —4 I ------ _ 3. Block _----__ 4. Lot

5. Type of Facility 6. Name of Building

II. BUILDING OWNER

7. Name EvJ s tA L~1N ~__-C c> OLQ—_ 8. Contact Person -

9. Tel. # P- ) off Fax # ----------- ''D~I_~ 10. Address aI^~ (~ --__ City --- `1 ____ State -L Zip _LO U O A £ Ill. GENERAL CONTRACTOR

11. Name---------------------------------------- Tel. # —

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name (l 10~l. ~ -------- _13. Contact Person 0 15. Tel. # J 1 ' P 11 2 - 300 0 ____—,—__`—____—__ Fax __--_---------- 14. Federal Employer ID. #; 115. _--` 1 16. Address ~~v C~ ~ !Y ~_--__--- City _ 1 ~ --_ State /J I Zip LL22 —

V. THIRD PARTY AIR MONITOR ~r 17. Name A' 4 O_ (a r "J? S+ f~jC-18. Contact Person

19. Federal Employer ID. # --- -. 20. Tel. # QJ L. Fax 21. Address ~~ g -E Pf City CL'€b`~ ~ _---- State Zip L --- 22. Sample Analysis Laboratory___ ~`( / ~L /I^ 23. NYS DOH ELAP # E-

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

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

Shift from: ❑ am ❑ pm to _--__ ❑ am 0 pm N 2

-----------------------------------------------

Access to inspect the premises must be provided during the work schedule indicated in this item. .11.f I 0 2 2002 ,)EP18ANHM 25. Total amount of asbestos-containing material to be abated during this work 4r ?ESTpSILE~ M , P5 Square Feet, and/or _--- Linear Feet ,~ T 2UG 9 qtP MOW

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NYC-WTC 000111102