Asbestos project notification form, Zone I Originals

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION

1 C1.oE.4gt Asbestos Control Program D~ 59-17 Junction Boulevard, 8th Floor, Corona, NY 11368-5107 Building Dept. or TRU No — ONLY I•rr1P FOR OFFICIAL USE ONLY TYPEWRITTEN ~ "O'M,cH ii~n~ cd" ASBESTOS PROJECT NOTIFICATION FORMS WILL BE ru (ASBESTOS INSPECTION REPORT) 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 p _ C ff r'r►~ n~ 1 ~~ g t —" Borough —_(— Zip

AKA 3. Block 4. Lot

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

7. Names P11 8. Contact Person `J- S_~CSSo 9. Tel. # P11 Fax # -------------

10. Address; P11 L_ City J ^~Z_l _1----_ State N Zip _O179

Ill. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ~ -G_.' .1._._._._._._._. _-- ---_13. Contact Person C 14. Federal Employer ID. # PII 15. Tel. # J `L 6 - 2 _2 -346 O — Fax # _5I L2 16. Address ol- 8(~l? ~_--__--- City ___) / L/ _--_ State &' Zip _LL22 _

V. THIRD PARTY AIR MONITOR `r 17. Name ___ G'L S+fC—_18. Contact Person 19. Federal Employer ID. #_._._._._ P11 20. Tel. # ( ~Q — Fax # I

21. Address L_ `` --- City ` s State N_ Zip

22. Sample Analysis Laboratory— ~ (EI`<<(« G- *6 0 7 r°t~S l( c — 23. NYS DOH ELAP #

VI. PROJECT INFORMATION 24.. Starting date for this portion of work __—__----_ Projected completion date

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Fri

Shift from: __—_— ❑ am ❑ pm to _--__ ❑ am 0 pm

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

Square Feet, and/or _—_—_ Linear Feet '7 B'j AU Or E1laR0':NZIITAt D1

ASi2".t1S Cr.}~;RGI ml,9

NYC-WTC 000111112