Asbestos Project Notification Form, Corona NY

NYC 9111 Public Portal Document

DEPARTMENT OF ENVIRONMENTAL PROTECTION 4 Asbestos Control Program 59-17 Junction Boulevard. 8" Floor, Corona, NY 11368-5107 g(7fl E Damt~l ~~ ' ASBESTOS PROJECT NOTIFICATION Building Dept or TRU No FOR OFFICIAL USE ONLY ITTEN ' \t . RMS WILL BE r"` 11O (ASBESTOS INSPECTION REPORT) 1. ACCEPTED '" !°!°'!'~~. 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 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.

I. FACILITY

2. Address i?E g 1~ -~ ` Borough I'- Zip I O C

AKA 3. Block I. L 4. Lot 1

Type of Facility, 6. Name of Building

II. BUILDING OWNER

7. Name S CSD 8. Contact Person o 9. Tel. # JL) 5t 0 7"4 03 $ax# 10. Address _~~ ~L —_ City --J _1 State [ ' ip _

III. GENERAL CONTRACTOR

11. Name ----- Tel. # — --

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _ 'e ~~ `-' 11O ( - --C-- _13. Contact Person c ~ ? L_ 14. Federal Employer ID. #[------------ P11 ._._,_._._._._._._._._. 15. Tel. # -2 L 3 0 Fax # J4-2V - 345

16. Address _301 jJZ*_ — — City J1 L'97 State /v Zip IL?

V. THIRD PARTY I)'t MONITOR A{ P tc-4'r N0L'Prr' . 17. Name v) ~f kT4 Z-E 6ki ^ ~ 1.rh C 18. Contact Person

19. Federal Employer ID. # 20. Tel. # e7 f=9a' 00J Fax # a" =! a 'O6 0

21. Address s~Jg1-4 ~if City State L Zip 00 / 22. Sample Analysis Laboratory— SC(fI~(if /F( - L ! j _ crc 23. NYS DOH ELAP # _ / I £Sd

VI. PROJECT INFORMATION 24.. Starting date for this portion of work CD2.1 0 2. Projected completion date U 3C Q 2 -

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

Shift from: 0 am 0 pm to 0 am ❑

If other, specify --

Access to inspect the premises must be provided during the work schedule indicated in this item. E 25. Total amount of asbestos-containing material to be abated during this work

Square Feet, and/or Linear Feet ACP pmC 21200 C1 : A'P rE' P~;tFNTA

tRu

NYC-WTC 000111124