Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

C;, vCW, NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program p 59-17 Junction Boulevard, 8°f Floor, Corona, NY 11368-5107 ONLY D .P Building Dept. or TRU No FOR OFFICIAL USE ONLY TYPEWRITTEN fh'"O"MrHravdaRScd' ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED ".":^r~.te.:a.r. (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 l C4A -M '~ Sl QE-E T — Borough —_~ Zip - 1 O 0 0T

AKA ---------------------- -------3. Block ----- 4. Lot - ______

5. Type of Facility. 6. Name of Building II. BUILDING OWNER

7. Name _L 8. Contact Person / + /C

9. Tel. #C~I---- o(o- :b Fax # - ------------

10. Address Nl'12P ~ City _ j_ . State/ vf Zip

Ill. GENERAL CONTRACTOR

11. Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name (~IL ----------- 13. Contact Person C 14. Federal Employer ID. # y. ._,_._._ P 15. Tel. # J 6 — 7~~ _3p6O Fax #__5L2_(3dCJ.S_ _ 16. Address O1c~ ------ City _tJ /rn~~ —_ State /~ Zip 1L2 __ V. THIRD PARTY AIR MONITOR

17. Name , a &_ ~? S, f C—_18. Contact Person

19. Federal Employer ID. # 20. Tel. # a .:2 E1_ Fax 21. Address g ~---- City SLLcY`~ e J___--_ State ice Zip L__ 22. Sample Analysis Laboratory___ —.l (( J! r-Af — 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 ❑ Friday ❑ Saturday ❑ Sunday

Shift from: ❑ am ❑ pm to _--__ ❑ 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 8•1^Ao Or :PA•: D1

rout'

NYC-WTC 000111175