Asbestos project notification form, DEP Box 39

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ,rP 4 Asbestos Control Program 59-17 Junction Boulevard, 8°i Floor, Corona, NY 11368-5107 Building Dept. or TRU No O AI FOR OFFICIAL USE ONLY

"rkiio~` ASBESTOS PROJECT NOTIFICATION LL aE (ASBESTOS INSPECTION REPORT) .PTED

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.

1. FACILITY

2. Address _L11 P~ G ST Borough tJ — Zip 1 o e 13 AKA, 3. Block L 4. Lot '

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

II. BUILDING OWNER

7. Name S I fij O r— i '8. Contact Person 9. Tel. # _— Fax#

10. Address —~— _ City ----_ — State Zip _

Ill. GENERAL CONTRACTOR

11. Name_-- ----- Tel. # —

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name __13. Contact Person /44 ——'L

14. Federal Employer ID. # PII _ 15. Tel. # ---/_ `—_ 0 r1'3 Fax# _--51 —2 i —~-- 5 t 16. Address ol~ j . ____ City J /~'~ ~L __ State N Zip ID _

V. THIRD PARTY AIR MONITOR ` r 17. Name k1 _ kP4ZE12 J i )S+ Pc 18. Contact Person V1 4+ EL (oG.Pcr4 .

19. Federal Employer ID. # 20. Tel. # a(P -_ - 00'1:.._. Fax # z~a~~a 'O D 21. Address ~~ g 1 a'` S'(~ City W ^L 2 J State _ Zip .J" ( i<7

22. Sample Analysis Laboratory— Ste( ( - r *6 CIZA7!(ES(T&t( 23. NYS DOH ELAP # / y -

VI. PROJECT INFORMATION 24.. Starting date for this portion of work _I IO OZ Projected completion date L Z

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

Shift from: _ ❑ am ❑ pm to ❑ am ❑ pm

If other. specify --- — _— Y REcWEO Access to inspect the premises must be provided during the work schedule indicated in this item. Jitf 05200? ^' 25. Total amount of asbestos-containing material to be abated during this work J NRANHM EST$ MAt. w 3 _ Square Feet, and/or Linear Feet TR2lJG ACP7 r 7 ?1200'

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NYC-WTC 000111098 (J