NYC 9/11 Public Portal Document
NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
109
i~~ 0b"'Ar Asbestos Control Program
59.17 Junction Boulevard. 8°' Floor, Corona. NY 11368-5107
L1t7M1 iO L
euadng oeoc or TRU No
FOR OFFICW. USE ONLY
TYB ASBESTOS PROJECT NOTIFICATION
LL BE (ASBESTOS INSPECTION REPORT) 1.
, QQPTED foe
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 OEP not less than one week in advance of the start of abatement activities.
I. FACILITY
c1 ~O
2. Address 9' W k-2 V 2Til2 ET Borough Zip _L
AKA 3. Block 13 7 4. Lot
5. Type of Facility 6. Name of Building
H. BUILDING OWNER
7. Name1U G~ 1v W A~ LL -.0 ' 8. Contact Person 11 A-N4 M A'I 1-+
`G~~ "it
9. Tel. # I ~ - ~-(1 ax # Id`h~ 9
.----------------------------------------- .-.-.-.-. .
10. Address .-...-.-.-.-.-.-.-.-.-...-.-.-.-.-.-.-P.....-.-.-.-.-.-.-.-...-.-.-.-.-.-.-.-.-....— City " StateN' Zip . ,O pp3
III. GENERAL CONTRACTOR
11. Name Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name e1L Tvo`-' ~O 13. Contact Person ___SL____
14. Federal Employer ID. # j Pu1 ,15. Tel. # 516 - 2 j -340 0 Fax ~W- 3dV S
16. Address _City ) /! _ _ State Zip IL?
V. THIRD PARTY AIR MONITOR
17. Name (/22 2 &lZr CP 18. Contact Person V41tci4*j (oC kr-I.
19. Federal Employer ID. # _____ 20. Tel. # a(3 - as - OOJ Z Fax # 2.1a — ~a
21. Address ~2 LL 1 City _ b7=~ State Zip 0O
/
22. Sample Analysis Laboratory_ SC (~((1=(L L'473' 7(`#'(ES ctc 23. NYS DOH ELAP #
VI. PROJECT INFORMATION
24.Starting date for this portion of work 7-- D Projected completion date _J_ J_
Asbestos work schedule ❑ Monday 0 Tuesday ❑ Wednesday 0 Thursday 0 Friday ❑ Saturday 0 Sunday
Shift from: ❑ am 0 pm to 0 am ❑ pm MEE
19
If other,
specify _ _
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 -3
8 tPS° Square Feet. and/or Linear Feet
e
ZI I~ ACP
CJR~A7 ~' J. t! 212001
iP ;
IFII
NYC-WTC 000111096
OCR can misread numbers and units. Confirm readings against the page image before using them.