Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ~yO N Asbestos Control Program 59-17 Junction Boulevard, 8"' Floor, Corona, NY 11368-5107 ONLY DP ASBESTOS PROJECT NOTIFICATION Building Dept. or TRU No FOR OFFICIAL USE ONLY TYPEWRITTEN ~ FORMS WILL BE - (ASBESTOS INSPECTION REPORT) ACCEPTED ~ww• yc.torlat~ 1 (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 J _ C_IM _2,5 1 Borough _t'-) Zip Do 07

AKA 3. Block 4. Lot

5. Type of Facility_............. . _6. Name of Building II. BUILDING OWNER I I p 7. Name J!+ C_~ ~Q S Ste__ -eT ' 8. Contact Person

9. Tel. # —__ Fax # 10. Address C 3f L&L City S .l- State '. Zip 0 9 (9 - ill. GENERAL CONTRACTOR 11. Name Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name (i 'eIL G ) __13. Contact Person __c~/

14. Federal EmptoYer ID. # PII ._._._._._._._._._._. 15. Tel. # c1 I

16. Address 00~ 1~ ~ City LJ Td/ h _ State /v Zip IL?

V. THIRD PARTY Al MONITOR

17. Name __ 1r' r *? (ZEtZ GI S ~18. Contact Person _p14 L ,~ r L 19. Federal Employer ID. # ` P 11 20. Tel. # 0(a - as -Q0 ~-- Fax # a UP - 06 3 0

21. Address g l 1 -- City -' 6 ~ State zip _(e (

22. Sample Analysis Laboratory__ (47(ftc- I. a c 23. NYS DOH ELAP # Lt' . _

VI. PROJECT INFORMATION 24. Starting date for this portion of work Projected completion date

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

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 Linear Feet 7 PJP.EAU Or E!nP )t kEJ.1ECi:iHi*! 3 Ery'FIJRE ryy 8 T)$ PRCCP.AI 1811

NYC-WTC 000111163