Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

"~,~~ NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION

ONLY TYPEWRITTEN FORMS WILL BE ACCEPTED ~ Dt~P ``~? ^.~.„.:^r5.sp~/~~r Asbestos Control Program 59-17 Junction Boulevard, 8 Floor, Corona, NY 11368-5107

ASBESTOS PROJECT NOTIFICATION (ASBESTOS INSPECTION REPORT) —

1. Building Dept. or TRU No FOR OFFICM USE ONLY

(See fee schedule) - I 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 L1__ Q nn —N —— Borough -- Zip J o l —_

AKA 3. Block 4. Lot

5. Type of Facility___-------- - —__--- 6. Name of Building ---—_-------` "' `t BUILDING OWNER \(U~~i, c VV li' IQ 1 is

7. Name ~ --~ Q~-~ _ 8. Contact Person 22 ,%

9. Tel. #a~ 1i22 2 Fax # - ------------

10. Address I L Lo►J g iR City --J= --_____ State 0_~zip

III. GENERAL CONTRACTOR

11.

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ell L' --- _1 (of t ob0 Z ---

14. Federal Employer ID. #J !II 15. Tel. # __L i27 'r

16. Address _ oLc~ 1! I' --------city J _

V. THIRD PARTY AIR MONITOR try' f 17. Name - ~,'~~ ~'gt . `'-~- Q kr(ZE2 /J i ??S PC ~j 18. 1 `

19. Federal Employer ID. # P _ 20. Tel. # t _ (_~ _r}€yJ 21. Addressg' L 1✓~'~ City --- _( 22. Sample Analysis

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 — 0 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

Zd — Square Feet, and/or ____ Linear Feet 7 )i 4E7:...7r~1 3 e`, C;,i i~'CEf.7u~T tBCI FF~CaA1.f tru

NYC-WTC 000111187