Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

Tocz9 thrc ~ 0 NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION

A Asbestos Control Program 59-17 Junction Boulevard. 8'" Floor, Corona, NY 11368-5107 r Building Oep. orTRU o ON FOR OFFICIAL USE ONLY ASBESTOS PROJECT NOTIFICATION aE MraiiA~c (ASBESTOS INSPECTION REPORT) ,. (Sie feee 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

2. Address I. O 1 -2~t-~1' " - t ~T Borough 4 Zip ( O O (3

AKA 3. Block . ' 4. Lot

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

7. Name_. . . . . . . . . . . . . . P1.1. . . . . . . . . . . . . T' . WL- • ' 8. Contact Person M ° "d~I t3 C (A- 9. Tel. J~._._._.-_. ._# ,.1 10. Address _L~ 5J.. SF _City __ = State(" Zip r oo 13 III. GENERAL CONTRACTOR

11. Name_ _ _ ____ Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _ _elL 1. 4 . l ._._._._._._.__ .__ ___13. Contact Person _ ~ -- 14' CC 7z~ -300 0 CC 14. Federal Employer ID. _._._._._._._.; 15. Tei# J __ Fax # J!' ~d ado

16. Address o1c7 J~' __ __ City _ State N Zip ILZ 3

V. THIRD PARTY AIR MONITOR

17. Name t vl E~NG fc_18. Contact Person I% C(fikf'L r(oL/fir( . 19. Federal Employer ID. # 20. Tel. # ar3=~AP - 00.E _ Fax # 2a '2a ' 0 .3O

21. Address ~ g k~1 ' _ City , - 1 State t. ` _ Zip OO

22. Sample Analysis Laboratory__ [£ (F(L h ~° '~~S tc 23. NYS DOH ELAP # _ / f -O

VI. PROJECT INFORMATION I' 24, Starting date for this portion of work 1211OZ Projected completion date 2_ j 0

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

Shift from: 0 am ❑ pm to ❑ am ❑ pm

If other, specify __ __

Access to inspect the premises must be provided dung the work schedule indicated in this item.

25. Total amount of asbestos-containing material to be abated during this work

55 Square Feet, and/or Linear Feet ACP 2!200 c tSd;C'JS C'w:RC•l PFf,~P;,fl tFil ~

NYC-WTC 000111138