Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

V„y,0,Aft NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ~'.° 1. Asbestos Control Program ~' 59-17 Junction Boulevard, 8" Floor, Corona, NY 11368-5107 Building Dept. or TRU No ONLY fl ~I P FOR OFFICIAL USE ONLY TYPEWRITTEN OkrH ru va°Ric°? 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 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 -ArY►~> _S S ~~ I Borough — N *-- Zip

AKA ------------------- ------ -- 3. Block ..._ 4. Lot -------

5. Type of Facility _-- _ — 6. Name of Building

BUILDING OWNER

7. Name _-MATi --_ 8. Contact Person I S 0)*& 9. Tel. # ~IZ~ 32= P Fax # ------- —(— (~

10. Address _1I ~~_—C -M~{~QS __ S ~_ City -- ---_ State — Zip _

III. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _j ?IL pp -L%~`-' ! I_._._._._._._. ____ _ --13. Contact Person _ ~ Ls✓ 2 L~ _

14. Fe era/ Employer ID. # P11 15. Tel. # 2 34 ' .9_.... Fax # _ Jc L 2_ '

16. Addr ss _olc~~LLUtL 1 !v `~_--- --- City ---- ~ --- State Zip _~LZL

V. THIRD PARTY AlR MONITOR ,~ r 17. Name y~v 2 _V z Nrf^~ f-18. Contact Person ~LE L ''` mo t^

19. Federal Employer ID. ft 20. Tel. # a( -~aa = oQ — Fax # 21. Address g> L L_ /-- City `€1 ~` State Zip

22. Sample Analysis Laboratory ~( /~«— h A6 It~S r- t-/'C 23. NYS DOH ELAP #

VI. PROJECT INFORMATION

24.. Starting date for this portion of work Projected completion date

Asbestos work schedule ❑ Monday ❑ Tuesday 0 Wednesday ❑ Thursday 0 Frii

Shift from: __—_— ❑ am ❑ pm to ____ 0 am ❑ 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 _—_—M Linear Feet 7 Dl 8': Ay Or Ef as <;e, WS Cr .~1R2L P6CCR~td

NYC-WTC 000111158