Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

7' .?T? W NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION OWL 1/ok) 'a"* Asbestos Control Program , < a 59-17 Junction Boulevard. 8°i Floor. Corona. NY 11368-51071, 7Y%i~41 Building Dept. or TRU tro 1- DADP : FOR OFFICULL USE ONLY ONLY TYPEWA! NtN1~ ,~~ ASBESTOS PROJECT NOTIFICATION FOR ~ ._ _ • -- (ASBESTOS INSPECTION REPORT) 1. (Sedfee 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 L EAbE S I ~~ £-7 Borough Zip

3. Block 4. Lot AKA —

5. Type of Facility ---- 6. Name of Building

II. BUILDING OWNER

7. Name M Ic W (1 Z 8. Contact Person' (

9. Tel. # 1-- Fax # —

_ City ---J State j~LlZip _ O

I11. GENERAL CONTRACTOR

11. Name_------ ----- Tel. # — ----

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name '?'~ em u" -------- --------13. Contact Person _.O — L1

14. Federal Employer ID. #! P 11 15. Tel. # J i /_ t —_ 300O — Fax # I _;Wl JdS-s 7~ , 16. Address _301 J1.~(_2 — City J fill 1 ' -- State /V Zip 1L213

V. THIRD PARTY AIR MONITOR 1 r Arf ZFrL (ii►ft~Z-'S rh C 18. Contact Person ti4 fyoL h-r~ 17. Name ~4J

19. Federal Employer ID. # ___-- 20. Tel. # 2~~ a - 0o Fax# 2I • c9 -O6 3 0 City _~~ State Zip 00 ( . 21. Address ~~ g~ L— ~— t ic $~✓~ _~ ' ---

22. Sample Analysis Laboratory— _1 (1 4 -___ o P 23. NYS DOH ELAP #_

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

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

Shift from: — 0 am ❑ pm to 0 am ❑ pm 7 9 If other, r0 ~ specify ------- — — -- REc 1EO c

Access to inspect the premises must be provided during the work schedule indicated in this item. t' 1. 2 . v6 2002 -+ 25. Total amount of asbestos-containing material to be abated during this work ^!%`•I O~ Square Feet, and/or Linear Feet / ACP snot C:?fA'1;Ir f9'.'io^;I ctA~l 4Ct'C'.PF.•Y 3 Er,r':,~f%:EhT Gds"Oj C%;~RGL P6f,,,F;,E1 tFiry

NYC-WTC 000111094