Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

,&7,sw-' o41! ovyj~ h. NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program + 4 59-17 Junction Boulevard, 8'" Floor, Corona. NY 11368-5107 Building Dept or TRU No FOR OFFICIAL USE ONLY

uiilo~o ASBESTOS PROJECT NOTIFICATION S WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED "r~.i!•her, 1 (SeS 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 n 2. Address 1 ~ 3 —~ 7~ S i(2 I (( Borough Zip 00

AKA _ 3. Block 4. Lot

5. Type of Facility. 6. Name of Building

II. BUILDING OWNER ~(Q `

7. Name NamFL L~ CioVJ so' 8. Contact Person

9. Tel. 4 )) q 1 25—lf≤ Fax # ~ ) n 10. Address _L5 - St 5~2~ 1 City _—.!= State t y ~1ip ' O 13

Ill. GENERAL CONTRACTOR

--- Tel. # — --

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ------ __13. Contact Person _ _ Lñ— /~ 14. Federal Employer ID. # P11 .15. Tel. # __--_ :16 -7 I--300o Fax# ~ _--r— 7d'3dCr,S 16. Address ~ C~ ✓~ -- City J / 1 ~ ~ — State /J I Zip

V. THIRD PARTY Alit MONITOR Ar 17. Name v ~ ~T t ZE tZ j./Gr!Fe "~? V rh C_18. Contact Person -6L ''` 0 L

19. Federal Employer ID. # ___---- 20. Tel. # ' ( .L as - 00~ — Fax # Lf22 -0 3 0 21. Address ~~ g 1 ~{ -- City I2! I .____ State IL7t. Zip L 00

22. Sample Analysis Laboratory— C_( ( (~l L /-,4 _9A /;?/ES A t ( 23. NYS DOH ELAP # _ f' t7 VI. PROJECT INFORMATION 1 I 24. Starting date for this portion of work _ Ia _ Projected completion date ~1 5 oL

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

Shift from: ❑ am ❑ pm to ❑ am ❑ pm ~~~ •1C

If other, specify - -----_-- — -- lh RAVED Access to inspect the premises must be provided during the work schedule indicated in this item. JUN 2 8 20O amount of asbestos-containing material to be abated during this work 25. Total JA0 Square Feet, and/or Linear Feet r RUG ACP o~.tl, 6 2/200 C1PEA1I;Ir ' tZ'[')5 C'h7RCi'sEhT trn IGu

NYC-WTC 000111145