Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

•r NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION '~A. Asbestos Control Program 59-17 Junction Boulevard. 8' Floor. Corona, NY 11368-5107 — Building Dept. or TRU No A ONLY FOR OFFICIAL USE ONLY TYPEWRITTEN ~%~ ~c ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1 ACCEPTED w. :nvc.aevrorr (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 n r 4 2. Address > IL ~s! Ct —__ Borough —J ' L— Zip _ 00 —

AitA —__ t0 — Mu d — --- -- —_ 3. Block 4. Lot _--- —

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

II. BUILDING OWNER

7. Name I BIV —~E == 2~ t_ --_ 8. Contact Person

9. Tel. # 31 Z=S g 3S__ Fax # _---~- 'r 10. Address _ O C>%-I — City VA•L_I.E- S Lk£A1'~ State Zip _ll Sot_

III. GENERAL CONTRACTOR

11. Name N— _ -- Tel

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name camel` ~U ----------- 13. Contact Person _~ ~ _ Ls✓ I _

14. Federal Employer ID. # 1 P11 15. Tel. # 6' Fax # 16. Address QJ — City L 2.J/ --_ State N Zip

V. THIRD PARTY AIR MONITOR Ar 17. Name G{ ) R&J ~_ ZE 2 G A S+f C—_18. Contact Person

19. Federal Employer ID. #; P11 20. Tel. # aLa=qaa =00 Fax # ZI =G _ —

21. Address S (__ 'F~ _ --city ~ __--_ State N Zip _LOO (_ _ / 22. Sample Analysis Laboratory— S~ t (fit L ~ Mg a f °7'tC-S 'L-r — 23. NYS DOH ELAP #

VI. PROJECT INFORMATION 24.. Starting date for this portion of work _—__----_ Projected completion date

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

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

If other, specify _----____—

Access to inspect the premises must be provided during the work schedule indicated in (his item.

25. Total amount of asbestos-containing material to be abated during this work

55 Square Feet, and/or _----- Linear Feet

:z ':j C^ 73~1 FFC6 rmi

NYC-WTC 000111170