Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

0111 Ql NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard, 8°i Floor. Corona. NY 11368-5107 Building Dept. or TRU No FOR OFFICIAL USE ONLY ONLY TYPEWRITTEN fD Pc ASBESTOS PROJECT NOTIFICATION "ONMrhruvi~n FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1. w:. ',v< =c:ld<f ACCEPTED (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.

1. FACILITY -- 2. Address S _ Borough __lam+ i__ Zip

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

5. Type of Facility, 6. Name of Building

II. BUILDING OWNER A /~ 7. Name —5 3 1v`1~1~1Lt't— L

9. Tel. # Fax #

10. Address _ _1—Wi E S __ 3 1 I! t City

III. GENERAL CONTRACTOR

11. Name------------------------------------

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ww~ --------- P11 14. Federal Employer ID. # ------------------- 15. Tel. # J i 6 _2 _300P _ Fax # ~rp ~, t 16. Address -'?0 q c~&L1 /_Y~ _ — City /~'( __ State /J 1 Zip .L12 _

V. THIRD PARTY AIR MONITOR Ar 17. Name -------~ t2¢~f hTt ZIE0 G i rEC S C -----_"~—~---------~ ------+— f --- 18. Contact Person

19. Federal Employer ID. # - P 11 20. Tel. # Jcq _ =0 0 .. — Fax #

21. Address p~ g ~ _~ _—_ City &12 _ State Zip

22. Sample Analysis Laboratory ~f c i' ~C- ~3~ -A!`r(~S A_r~ — 23. NYS DOH ELAP # LL Ic __

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

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

Shift from: __—_— ❑ am ❑ pm to _—M ❑ am 0 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

-V — Square Feet, and/or _--- Linear Feet 7 e'iKA'I deP 01 cl 1h7 ct;r.SCflitRGL rrn

NYC-WTC 000111180