Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program i 59-17 Junction Boulevard. 8 Floor, Corona, NY 11368-5107 !f4,'- Q`7or lS1'Ra Building Os ar — orTRU~ FOR OFFICIAL USE ONLY ASBESTOS PROJECT NOTIFICATION (ASBESTOS INSPECTION REPORT) ,. (Sic 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.

1. FACILITY

2. Address k O S2 I O n1 P—EA- 3~ - T Borough t *' I Zip (O O t.

AKA 3. Block S 4. Lot

5. Type of Facility__— 6. Name of Building II. BUILDING OWNER

7. Name J k S ' WL- 8. Contact Person M 9"' 4 I ^S C +fL 1`? t

9.Tel.# (Z #

10. Address _LQS. 1`_-€ 6 k. sue__ city __±L State( '1 Zip r O o 13 Ill. GENERAL CONTRACTOR

11. Name_ Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name 1-. .l._._._._._._.__—M---- __13. Contact Person __~ L_____

14. Federal Employer ID. # P11 15. Tel. # c1 - 300 0 Fax # c~i c 2~ 3d~5

16. Address 3L 2 ---___ City i k6f4 _ State /J Zip .iLZ 3

V. THIRD PARTY AIR MONITOR )) 17. Name t v ZE~NG r ^kg~ PC_18. Contact Person V'1tc: -EL .(oL r.1 . 19. Federal Employer ID. # 20. Tel. # 03 0'a- d0 — Fax # .2.1a _a '04_30

21. Address ~2 g 1 1 44$ ii City _61 -6 . State j~ Zip oO (

22. Sample Analysis Laboratory_ Sc(frr((FiL h t °_'1ES ~•r' c 23. NYS DOH ELAP # _ / f t7Lg-C

VI. PROJECT INFORMATION I' 24. Starting date for this portion of work 021 0 Z Projected completion date 2_ j J0

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

Shift from: ❑ am ❑ pm to ❑ am ❑ pm 6' If other, specify AV

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 L2 5 Square Feet, and/or Linear Feet ACP 2r2oo C.tFY 3 E`f;. Ei4 k:a EAET PFf,,,?;,fl tFa ~

NYC-WTC 000111138