Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

„ Y~,ART NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard, 8e Floor, Corona, NY 11368-5107 Building Dept. or TRU No ONLY D ~ ITM~ FOR OFFICIAL USE ONLY

TYPEWRITTEN r ~tiMrNluonc~`~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE - (ASBESTOS INSPECTION REPORT) 1. ACCEPTED ;w.^vc le+ldep (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 LZ ~~ ___ _—~ ---_— Borough — -- Zip

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

5. Type of Facility__----------_--__--- 6. Name of Building --- —-` --__—

II. BUILDING OWNER —_-------~~ "" \(at[ & V j L tCt t ' ,

7. Name _CG ~l ti 1 -- Q .-- — G _ 8. Contact Person 2 ___

9. Tel. #~a~k L722! 2! Fax # _ ----------- -

10. Address _— 1 L --_ofJ s~'(Z~~ 1— City — _ State i1~' Zip t l7 C7

III. GENERAL CONTRACTOR

11. Name_—__—_____ ----------------------------Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ~_-----------_13. Contact Person _ ~ _LJ✓~/~ _— y 14. Federal Employer ID. # 1 P 11 15. Tel. # ct o Fax # >' 2U s__

16. Address old~f~ `Z_- -__--- City / 1 _--_ State . Zip L]'2 _

V. THIRD PARTY AIR MONITOR A 17. Name _y~v Lt&_ !h l Zt 2 G 3? S fhhC 18. Contact Person

19. Federal Employer ID. #! P11 r__ 20. Tel. # QJ _DO —Fax

21. Address g ~ ~ 1=r --- City ~w State ice Zip

22. Sample Analysis Laboratory___ l (FI`f (( ~C- o r-A f`~-'(£S cr — 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 0 Frii

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 It P D1 B~ f:Al Ar f'!'lIA^•••,~,l~, f

rIII7.1 rra 7

NYC-WTC 000111188