Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

O _S 2 I ~ NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ` v ,~ ~, /` J q~1 N Asbestos Control Program 59-17 Junction Boulevard. 8 Floor. Corona. NY 11368-5107 ONLY D~r /It ~~ ASBESTOS PROJECT NOTIFICATION Building Dept. or TRU No FOR OFFICIAL USE ONLr TYPEWRITTEN FOR ~Mtaruiao ~c`~ (ASBESTOS INSPECTION REPORT) 1 (Se 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 I 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 _11 —r U _g~S _S €- I Borough L-- Zip -)Qc _ 2~ AKA --11 C _I°-_~Ls S ~2 ~--_ 3. Block 4. Lot ?_—

5. Type of Facility_____--__--------__--- 6. Name of Building --- ----_

II. BUILDING OWNER ,~ /~ ~1 7. Name ~ _, f ` L~+C --_ 8. Contact Person r~^^C __

9. Tel. # J _l t~ 9ax # ------------- nn 10. Address _?_L. C __ ~i2^i_—__ S 1 --- City -- — _---___ State Zip _L .. .Li_ III. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR ,C! j~J~tl _13. Contact Person 12. Name ------ ( -----------

14. Federal Employer ID. # P1~ ._;15. Tel. # ~f c —__---_-- Fax Jc I ~VI/ --__------__— S _

16. Address -3_o1 241_Ls'-------- City ----/I L/> --- State N k Zip - LLZ~'L -

V. THIRD PARTY AIR MONITOR `r 17. Name S+pC - 18. Contact Person '-

19. Federal Employer ID. # 20. Tel. # a ~aa' ~~ — Fax #

21. Address ~~_` City [`( ---_ State l~ Zip J00 (L - 22. Sample Analysis Laboratory— _~ ~ ( t' (G ~/^ 9 fC-S ' — 23. NYS DOH ELAP #

VI. PROJECT INFORMATION 24.. Starting date for this portion of work ~~ 1 Q-2L.. Projected completion date ~~, Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday 0 Friday ❑ Saturday 0 Sunday

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

If other, specify --------------------------- ---------------- I ! IL 'D Access to inspect the premises must be provided during the work schedule indicated in this item. jury 2 2002 25. Total amount of asbestos-containing material to be abated during this work 1

Linear Feet ~~~. % _QUAD —__ Square Feet, and/or _--- 0" ACP; 21200

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NYC-WTC 000111132