Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

E O ~t 4 YC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program Ar 59-17 Junction Boulevard, 8°i Floor. Corona, NY 11368-5107

KITTEN D:,P: ASBESTOS PROJECT NOTIFICATION ORMS WILL 8E `"`"` jO (ASBESTOS INSPECTION REPORT) ACCEPTED

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 l ~3 E r 2E E T Borough N~ Zip t 00 t♦ 3 nn AKA I 0 — t0 CJ • __ 3. Block -- 4. Lot _

5. Type of Facility, 6. Name of Building

11. BUILDING OWNER

7. Name _ _ 9(L D/ rlA`I - -- I' (. Contact Person

9. Tel. # _ — Fax#

10. Address iiI2cQ-°--_ &L. City -- IN_ 1 State t 'fZip..J 0~

III. GENERAL CONTRACTOR

11. Name_________ ...._---- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name eIL ------ —_13. Contact Person t?c Lil- / ? 14. Federal Employer 10. # —~ -2 1- 3060 15. Tel. # 66- i Fax # ---~ _—_

16. Address OlJc_2' 1~_------ City g__ State / Zip J _

V. THIRD PARTY AIR MONITOR

i44L Nof^p_( 17. Name _ (v ) ~j_ 2 -Ea NG i^ka~'~S,f PIC 18. Contact Person 19. Federal Employer ID. # ___----- 20. Tel. # a r3=~aa - 0O — Fax # .l 0

21. Address ~~ g1 C r{ Z — City /(k1A _T.Q=&— State Lam _ Zip _(0o

22. Sample Analysis Laboratory— SG(mot I; t I( r7 i 23. NYS DOH ELAP #_ (f O

VI. PROJECT INFORMATION

3O_jôa // ~~ 24. Starting date for this portion of work _Sp 7 _ Projected completion date — Asbestos work schedule ❑ Monday 0 Tuesday 0 Wednesday 0 Thursday 0 Friday ❑ Saturday ❑ 'f. 1 Shift from: __ 0 am 0 pm to 0 am ❑ 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 U Square Feet, and/or — Linear Feet fN ACP 21200 O ' .Sc'4xi tFu

NYC-WTC 000111120