Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

(A'r NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard, 8'" Floor, Corona, NY 11368-5107 DP Building Dept. or T U No FOR OFFICIAL USE ONLY

ndr O ASBESTOS PROJECT NOTIFICATION MS WILL BE (ASBESTOS INSPECTION REPORT) 1. ACCEPTED _.••.~rc.jeira.r 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 n 2. Address .E (J — S~~~ Borough _ti __Borough Zip

AKA —____----- --------- ----- --- —_ 3. Block ----__ 4. Lot _---

5. Type of Facility_____— — 6. Name of Building ----- II. BUILDING OWNER~ 7. Name -E__ f FF IT !f — —_ '8. Contact Person _-------__---__—

9. Tel. # Z7 9 l- S ax # - ____________

10. Address ~,. J3 Qt-2 IJ S LQ ~~ ( _City -- N ~__--_____ State M`1 Zip

III. GENERAL CONTRACTOR

11. Name --- Tel. # ------__------

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name `vo`! 1 ~C~ ----- 13. Contact Person

14. Federal Employer ID. # ` PII ~~f / ~dCJ •5 Fax # ------------------ J~ _ Tel. #

16. Address ~_ -- __-- -City / '~/7 `~_--_ State Zip _LL22

V. THIRD PARTY AIR MONITOR

17. Name ~ ) ~ _ fC—_18. Contact Person •-

19. Federal Employer ID. if ------ ------------ 20. Tel. # Q ( _1aa =mac 1- Fax # - 21. Address g> ( ✓~~ —/-- City [`L€ __--_ State Y Zip 2L

22. Sample Analysis Laboratory—_ -J (~~G-~^ a rte! T-!~S ct — 23. NYS DOH ELAP #

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

Asbestos work schedule ❑ Monday 0 LO ~' Projected completion date _

Tuesday ❑ Wednesday ❑ Thursday 0 fP4 Friday 0 Saturday ❑ Sunday

Shift from: __—_— ❑ am ❑ pm to _-- ❑ am ❑ pm

If other, specify t:

Access to inspect the premises must be provided during the work schedule indicated in this item. 1111 0 2 25. Total amount of asbestos-containing material to be abated during this work ~EPIBANHN. l ROGRAM O) Square Feet, and/or _--- Linear Feet T?UG ACP 7 2/200,, IraCE7.7il.T rcr.~a~r.I:x..E airrli J` rra

NYC-WTC 000111106