Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

ty+~~ an 004" S,4 NYC DEPARTMENT OF ENVIRONMENTAL PROTECT Asbestos Control Program m 59-17 Junction Boulevard, 8 Floor. Corona, NY 11368-5107 Building Dept. OI'rRU No ONLY ~~ FOR OFFICIAL USE ONLY TYPE ,;rKiilon° ASBESTOS PROJECT NOTIFICATION F (ASBESTOS INSPECTION REPORT) 1. V. .: ; •fit.}~~/yep . 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

2. Address 9of- EPt~ S l ~E-E Borough N Zip

i1 3. Block 4. Lot

5. Type of Facility_-- -- . 6. Name of Building II. BUILDING OWNER

7. Name _ WC -S M 0. ko W 1 - . 8. Contact Person M •

9. Tel. # ~ ] — 3 4 Fax #

10. Address City N_ State .!Lf_ Zip 1 0 0 1 3

Ill. GENERAL CONTRACTOR

11. Name_--- - — — Tel. # —

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _ ~IL co`_' 1O -----C— __13. Contact Person

14. Federal Employer I0. # ` P ~~ 1 . Tel. # c1i 300 0 Fax # 5L 2s 3 5 7t

16. Address -- City _______ State /U Zip ,1. ,23

V. THIRD PARTY AIR MONITOR ~r 17. Name \11 _ k1(Z~lL ' & LLf PC 18. Contact Person j'~~L

19. Federal Employer ID. # ___-----_ 20. Tel. # Fax # ~a=~a —off 3o

21. Address ~~ g / 1 e City _4'G -' 2Lt.. State - _ Zip 00 ( '

22. Sample Analysis Laboratory— SC( -- ((~~L f~ t ~ 'ffis v c 23. NYS DOH ELAP #__((1L -d

7 J3 O VI. PROJECT INFORMATION 24.. Starting date for this portion of work Projected completion date 3 tea`

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

Shift from: — ❑ am ❑ pm to ❑ am ❑ pm

If other, specify 7RECENE0 Access to inspect the premises must be provided during the work schedule indicated in this item.

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

Square Feet, and/or Linear Feet ACP 21200 Q~•,C;•t~iy d c•Fv ctt•AL '.a ':j$ t^d:Rc.&

NYC-WTC 000111092