Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

104 0 NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program IfV ON t+pip 4 59-17 Junction Boulevard, 8' Floor, Corona, NY 11366-5107 Building or TRU NO FOR OF`FFII'CIAL USE ONLY

'"~t"rK:iio~ ASBESTOS PROJECT NOTIFICATION BE (ASBESTOS INSPECTION REPORT) 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 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 k O S2 I. O n 1 PLEA' l~ S ~7^ 1 Borough t " f Zip (0 0 (3

AKA _ — 3. Block 1.. 9 4. Lot __________

5. Type of Facility_ 6. Name of Building

II. BUILDING OWNER

7. Name VI 1 ' V 44•_ 8. Contact Person I ^S

9. Tel. # (Z 1~ #

10. Address ~ 0 ~±`-e- SF —_ City __ N_ State(=1Zip

Ill. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name e I'CO — _ -- _13. Contact Person _ /c ) __ _______ P11 14. Federal Employer 10. #j._._._._._._._._._._._. 15. Tel. # ~j67~1 - 3400 16. Address _3QL _-- City J L _[__ State V/ Zip IL?

V. THIRD PARTY AlAIR MONITOR

17. Name 2 ► Zr'~ NG r "le l~ S+ rC 18. Contact Person

19. Federal Employer ID. # _---- — 20. Tel. # aft=1a2 O0 _ Fax # .tea e2a —06 3 0

21. Address City L State [~_ Zip (00 / 22. Sample Analysis Laboratory C(f ((~tL G- t °x'«S J c 23. NYS DOH ELAP # _./ f iL

VI. PROJECT INFORMATION 24 Starting date for this portion of work 2 0 Z Projected completion date _2..j3O O Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday 0 Friday 0 Saturday ❑ Sunday 1 / S 1TZ)% Shift from: ❑ am ❑ pm to ❑ am ❑ pm

If other, specify N

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

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

15 ' Square Feet, and/or Linear Feet

1!P • t' ~p,•7~£f1rAL

P6fuP:.f.1 tpn

NYC-WTC 000111140