NYC 9/11 Public Portal Document
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NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
Asbestos Control Program
59-17 Junction Boulevard. 8'" Floor. Corona. NY 11366-5107
FOROFDept or
FIdAL USE
No
1
TY !r5irtcR
°t ASBESTOS PROJECT NOTIFICATION
BE (ASBESTOS INSPECTION REPORT)
D 1.
When submitting this form at the NYC Department of Buildings. the original form and three (3) copies with original
V 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 Q jAe7 e O ftrb S ('r ( Borough 1 Zip 10 ID O 7
AKA 'la C 4-1 ç __Y3LA)LC. 3. Block 4. Lot
5. Type of Facility__ — 6. Name of Building
II. BUILDING OWNER
7. Name Cu t S ._C 8. Contact Person,)LrrtA CokL 1 .
S Fax #
gam / ~1
10. Address ~ City _ f V' I State ip /00
III. GENERAL CONTRACTOR
11. Name______ Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name .~O . -.-.-.-.-.-.-.- --__`_ _13. Contact Person L~
14. Federal Employer ID. # ---- rp I I j15. Tel. # c~l ~ - 7~~J
^00 O Fax #
16. Address (~ _~ — City ______State Zip t o
V. THiRD PARTY AIR MONITOR
P- `r
17. Name 1,' ) kT(ZE2 Gr S1 PC At
18. Contact Person Y` L
19. Federal Employer ID. # —__ 20. Tel. # aL - O0. Fax # -___ 0.3O
21. Address ~ g 1 ? City_ State N Zip 1 00
22. Sample Analysis Laboratory— i(f1'-(fi(F L 4,*64 917c)_'lEs crc 23. NYS DOH ELAP # _ / / d
VI. PROJECT INFORMATION
24,. Starting date for this portion of work (Q fgi C) 01 _ Projected completion date 7 / 2 0 LD~
Asbestos work schedule ❑ Monday ❑ Tuesday 0 Wednesday 0 Thursday 0 Friday ❑ Saturda ❑ Sunday
Shift from: ❑ am 0 pm to ❑ am ❑ pm •. ~,
If other, - ►;,, • ~~
specify
— EIVED ',
Access to inspect the premises must be provided during the work schedule indicated In this item. fYWI
25. Total amount of asbestos-containing material to be abated during this work ` f
quare Feet, and/or Linear Feet
/—
s'p 9ev)
14 1 (00O \ fACP7
212001
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KdZ'JS C^,7
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NYC-WTC 000111114
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