Asbestos project notification form, Zone I Originals

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard, 8"' Floor. Corona, NY 11368-5107 — -- ta Building Dept. or TRU No ONLY FOR OFFICIAL USE ONLY MrNrµ:~°R°°~. TYPEWRITTEN ~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1 nww: nYe..Sovl9e~ , ACCEPTED (See fee 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 [[~~,~ 2. Address _ I_IP___C-ff ~" II ~S g I __~ Borough _J—_ Zip

AKA 3. Block 4. Lot

5. Type of Facility 6. Name of Building II. BUILDING OWNER r -

7. Name =____ _ ._ PII ._ _ ._._._._._._._._.' 8. Contact Person ' J_ SLC.Cti o e

9. Tel. # P11 ;Fax # _------ Y ----

10. Address_._._._._._._ _._._._PII city1LJ _T._...._............. . State .!'4LJ. zip _O r73 9 III. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name elm ------- _13. Contact Person

14. Federal Employer ID. # 1 j15. Tel. # J :_2 ^3460 —Fax #

16. Address -- City _J / L/ /_--_ State .L)_'(Zip _LL22 _

V. THIRD PARTY AIRMONITOR ..

17. Name rson .— ._--.-------} - -- 19. Federal Employer ID. # P11 _ Fax #

21. Address _—_ State (~ Zip

22. Sample Analysis Laboratory—_ S'c_1 (( NYS DOH ELAP #

VI. PROJECT INFORMATION

24.. Starting date for this portion of work

Asbestos work schedule ❑ Monday ❑ Tue Fri,

Shift from: _—_ ❑ am ❑ pm

If other, specify —----------

Access to inspect the premises must be provided durir

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

Square Feet, and/or _____ Linear Feet 7 8~7^A11 Or Eff.Pp•'NEI:Tn( )1 F" tOS iJ :•l:R { tiT tru

NYC-WTC 000111111