Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION '' Asbestos Control Program DA ■~ 59-17 Junction Boulevard, 8"' Floor, Corona, NY 11368-5107 Building Dept. or TRU No ONLY FOR OFFICIAL USE ONLY ~~+ ASBESTOS PROJECT NOTIFICATION TYPE EWRITTEN FORMS WILL BE h''+aNMrNfavao~`c°r (ASBESTOS INSPECTION REPORT) ACCEPTED ww."r9 tua~er 1. (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 ~ ~"11r! 15~A• 5~ -- Borough —~-- Zip

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

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

7. Name 1vll~ll t't l L- l—G --_ 8. Contact Person

9. Tel. # Fax #

10. Address ~~ S 1 1lo City --~~+ _ 1 __-- State l" j_ Zip

III. GENERAL CONTRACTOR

11. Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ~U __ ____ 13. Contact Person

14. Federal Employer ID. # ? -~~ P11 5. Tel. # ._2i.-346 O /6 - Fax # 5L I 3d~s

16. Address 0 ~~1v~_--__--- City ~tJ (/~~i _-- _ State /v Zip _LLZ~' _

V. THIRD PARTY AIR MONITOR

17. Name y 22 f ,r~k~S C 18.Contact Person _~Lf l- ~'~^

19. Federal Employer ID. # P11 20. Tel. # _~~a-~aa 1 _. Fax # 2I 2=0~ D - 21. Address g> _( __$Lf z —//-- City €t ~7~G State Lam Zip

22. Sample Analysis Laboratory___ '( ( fC- °~-'t tr — 23. NYS DOH ELAP #_I —_ _

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

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

Shift from: —_— 0 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 u i 4D lJ_ Square Feet, and/or _—_--- Linear Feet 7 .) Oi 8,P%A!I o; tP Adt;t) Ct a c. ;..IT rnn ~

NYC-WTC 000111181