Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

cirr or. NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION a"" ' ' "~ti~ Asbestos Control Program DA I~ 59-17 Junction Boulevard, 8th Floor, Corona, NY 11368-5107 Building Cept. or TRU No ONLY 1~ FOR OFFICIAL USE ONLY TYPEWRITTEN '"Ok rw:~„~°~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED (See 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 _LOS - 1OL C Qr- ~ ( --- Borough _ A -- Zip _LO©I —_

AKA ----------- M ----- ------ -- 3. Block ----- 4. Lot ------

5. Type of Facility___--- ----- -6. Name of Building --- II. BUILDING OWNER 'p- 7. Name ----- —_ 8. Contact Person

9. Tel. # fax # -----------

10. Address ~~--~~Q__4E_—~1(1 1 City -- N ----- State!f Zip

III. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name (ho _ ~1 _c~ `---- _13. Contact Person _ 7J L~ _ C 14. Federal Employer ID. # PI ._._._._._. ._ .'15. Tel. # J 7 1~^ 3~6 0 Fax # JJ Z~ 3d~s

16. Address _ ol(D&V [L1_! ~ --------City —_ L~I 4—_ State L . Zip

V. THIRD PARTY AIR MONITOR r )) pp r 17. Name y_v (~ Oj_ cZr • NG i ~ f_18. Contact Person

19. Federal Employer ID. # ___--__----___ 20. Tel. # aIo~=~aa -00 T — Fax # 2-I~=~~~= 0 r✓ O _ / 21. Address g C-_9 J { —/-- City _[`~w State L~ Zip

22. Sample Analysis Laboratory____ 1.... ( ~L h b ( - tC- S ,-,r 23. NYS DOH ELAP # _L V _____

VI. PROJECT INFORMATION 24.. Starting date for this portion of work Projected completion date r, r-9 Asbestos work schedule ❑ Monday ❑ Tuesday 0 Wednesday 0 Thursday 0 Fri,

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

If other, specify _ ---_

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

Square Feet, and/or___________ Linear Feet

e c~',~wrbpi':~'~•rvt FFr,Ca:,:.l;ect rru ~

NYC-WTC 000111143