Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard. 801 Floor, Corona. NY 11368-5107 00 u A orTRU N P OFFXCl4L USE ONLY r 1̀►~" PEWRI7TEN ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1. ACCEPTED ="'p'.~!'r"P. 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 NYCOEP 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

'`r 1war '1'aM/ S Borough Iv ' p4tOt it 2. Address 3 AKA 3. Block I 4. Lot I f 5. Type of Facility 6. Name of Building

11. BUILDING OWNER

7. Name 5 3 M.A.''- • * 8. Contact Person Ea- U —C— 9. Tel.# ti Z! `L Fax# `` ,, 10. Address_) City______________ State ip

III. GENERAL CONTRACTOR

I1"Name Tel. # —

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name -- 13. Contact Person L" 14. Federal Employer ID. # s PII .15. Tel. # — t 6 - 7'/'3 40 0 Fax # I'p— 7~ 3c 85 ? / , ,~,_S ~C 16. Address JQ1~~~~ 1 ~y~ _City _J!(/'_7 State Zip IL?

V. THIRD PARTY MONITOR AlI n A 17. Name (',V hf ZED /~(G t - f 18. Contact Person 14t ` ' D("

19. Federal Employer ID. # 20. Tel. # a (~ - gas - oo Z Fax # 213 " ~a -03o r 21. Address sr~ g I1 'r (fE City 6 - State Zip 00 J 22. Sample Analysis Laboratory i(6t ((1t" - 1 A69 7~t 7E7!1ES tt ( 23. NYS DOH ELAP # 1/ Sf ~d

Vt. PROJECT INFORMATION 24- Starting date for this portion of work C) Z Projected completion date ' Z

Asbestos work schedule ❑ Monday 0 Tuesday 0 Wednesday ❑ Thursday ❑ Friday ❑ Saturd day

Shift from: ❑ am ❑ pm to 0 am ❑ pm

J :;;>> specify — 'ra,rvt(f Access to Inspect the premises must be provided during the work schedule Indicated /n this Item. JUN 2 8 2VtJL n~q E#RANHM 25. Total amount of asbestos-containing material to be abated during this work OR G ME'` p~ T2uG Square Feet, and/or Linear Feet O r .r 6 1$ 4B~!IP.tA~I 1• r rM,rE!1'.7P^.'7NcllTAl 3 t!_"tflAEhq versnal.r rmi~

NYC-WTC 000111178