Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION 30 ' 'k. ' Asbestos Control Program 59-17 Junction Boulevard, 8e Floor. Corona. NY 11368-5107

T DPc ASBESTOS PROJECT NOTIFICATION Building Dept. or TRU No FOR OFFICIAL USE ONLY TYPEWRITTEN FORMS WILL BE ' AO"MalrruviwR~ (ASBESTOS INSPECTION REPORT) 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 .

I. FACILITY

2. Address E Lt~ G ~-- Borough 1 1 zip t°0 13

AKA 3. Block 4. Lot

5. Type of Facility____ — _ _ 6. Name of Building

II. BUILDING OWNER

7. Name S -(A--- —~L~ — 8. Contact Person _' _ ~✓

9. Tel. # 10 SS1 Fax # _--- ---

10. Address P11 I City s[l~-L- __ State N'1zip_ Ill. GENERAL CONTRACTOR

11. Name----------------------------- ------------ Tel. # -----

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ell l_~J~ _13. Contact Person _ _/_ ---------- S~L_ _— 14. Federal Employer ID. # _._._._._._._._.PI I 15. Tel. # ! 7~~ 3060 — Fax # _ 1__ ~d~s _

16. Address old j J Y~ _—_ City _ State /V Zip 1L22

V. THIRD PARTY AIR MONITOR

17. Name

19. Federal Employer ID. # 20. Tel. # _f ..

21. Address g> L ~✓~~ --- City €

22. Sample Analysis Laboratory—_~C( (/F(L G_ C r- 7c'Y_'I

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

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday

Shift from: __—_— ❑ am ❑ pm to _--_ ❑ am ❑ pm

If other, specify

Access to inspect the premises must be provided during the work schedule inolcatea in m is ,rear.

25. Total amount of asbestos-containing material to be abated during this work

Square Feet, and/or _---_ Linear Feet ,7 31 gr:1F~:a.'Y S_3E: ~•.~3 Lc•,am:,: r.••CEi«EhT ~l{

IGII

NYC-WTC 000111192