Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59.17 Junction Boulevard, 81" Floor. Corona, NY 11368-5107

TTEN IMP. ASBESTOS PROJECT NOTIFICATION L. For TRU No USE ONLV

t%?RiUWS WILL BE (ASBESTOS INSPECTION REPORT) I. ACCEPTED schedule)

When submitting this form at the NYC Department of Buildings, the original form and three (3) copies with originil 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.

1. FACILITY .~/ sf 2. Address l Rd— — (",,-' `! T E S l re iE-c-Y Borough_J zip 0 Q

AKA 3. Block 4. Lot 2-

5. Type of Facility 6. Name of Building

II. BUILDING OWNER

7. Name CtSS' "{ ` DC" ' 8. Contact Person

9. Tel. # Fax #

10. Address ~E S I City — State Zip

Ill. GENERAL CONTRACTOR

11. Name _ _ TeI. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ~ ._._._._._._._. N^ 13. Contact Person (:::1>Sl[sl-

14. Federal Employer ID. # PII ,15. Tel. # 1 l 6- 781 3°00 Fax # sl d3 s 16. Address t~ _CityJ3j i , '9f4 State Zip _10

V. THIRD PARTY AI)R MONITOR A~ fj' 17. Name ~'~/ i Lt ZE2 G rM l Pc 18. Contact Person V4114f* . (.(OG, ht4 . 19. Federal Employer ID. # M_ 20. Tel. # ' s - 00:' Fax # 2Ia 92P "06.3 0 a~ 21. Address g > 1 ( _s City r = ~1~_ State Zip (00 j ,a 22. Sample Analysis Laboratory If i'~ (' - L • & `! fES 't c 23. NYS DOH ELAP # t I g gtd

VI. PROJECT INFORMATION 24.. Starting date for this portion of work 1 t d Z Projected completion date a I 0 Z

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday 0 Friday ❑ Satur

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

.L~ (0 azc) Square Feet, and/or Linear Feet

tr»a~ l x

tRlI ~

NYC-WTC 000111165