Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

eo - "L NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard. 8° Floor. Corona. NY 11368-5107 4.AJ N 0 Build fi ~epL or TRU FOR OFFICW. USE ONLY E f ASBESTOS PROJECT NOTIFICATION (ASBESTOS INSPECTION REPORT) 1. t~ (S 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 ~1~, Address _IL 2. C E ~r I& —S l_ ~ - ( Borough Zip 1' O O '- ' ~_ (~I AKA 1LL- ~' ~T-~u~r 3. Block 3( 4. Lot

5. Type of Facility 6. Name of Building II. BUILDING OWNER

7. Name 91_3jrTM ta (~~ 8. Contact Person

9. Tel. #(3-t ) .4'7_'_I L Fax #

10. Address _ __ City Ni1 State Zip —1

Ill. GENERAL CONTRACTOR

11. Name' Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name , Iy e~ ~ ') ~O 13. Contact Person ~ ~c c P11 14. Federal Employer ID. # _._._._._._._._._._._._._._._._._._._._._._.15. Tel. # J 1 _ 7s ~_3O O 0 Fax # Jl--- 7d 3 0 t~.s - r 16. Address 'o1e7 v A/ City J / _`

'~ / State _Zip 1I ? 7'-?

V. THIRD PARTY AIR MONITOR

17. Name PC 18. Contact Person VVlic4 <-L t4t-&14 . 19. Federal Employer ID. # _--- 20. Tel. # 2(3=1't a - O0J - Fax # 213 2a -O6 .3 0

21. Address 22 g 1 — _ t FE 7 City State ~ Zip 100 / ( 22. Sample Analysis Laboratory— . (£!mot((~«- G A6 c rA `~rt cr c 23. NYS DOH ELAP # (/

VI. PROJECT INFORMATION 24. Starting date for this portion of work c:D.2 Projected completion date o-

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

Shift from: 0 am 0 pm to 0 am 0 pm

If other, specify _-- N RO~Nw s r Access to inspect the premises must be provided during the work schedule indicated in this item. .jut 0 1 2002 ='EP/BANHM 25. Total amount of asbestos-containing material to be abated during this work ~'ESTOS/LEAb ~RORGIROAM Jr O Square Feet. and/or Linear Feet l 2 r (j 00 ACP 7 lJptAy Or f ! Pi Wool L•.4 c. r' ^'JV£MAt a 3tt~7HC4AFAT ' s c'4 PtCP,n trn

NYC-WTC 000111136