Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

~;, 0,tar NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION '° ' .+dry Asbestos Control Program 59-17 Junction Boulevard, 8'" Floor. Corona. NY 11368-5107 ONLY f "".P. W ASBESTOS PROJECT NOTIFICATION Building Dept. or TRU No FOR OFFICIAL USE ONLY TYPEWRITTEN ~,roNMrNruvaon000 FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED " ^y :'•~'°~. (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 QQ //~~ .— n wl Q 2. Address _~IP —__!~E~~?~— LLS~~ — Borough 1V 1 -- Zip (

AKA —____-- 3. Block 4. Lot

5. Type of Facility__, 6. Name of Building II. BUILDING OWNER

7. Name S t~~~_--L~~~3`~L~ 8. Contact Person _3t,

9. Tel. # _. ---- ------, 10. Ad 11 Stat: P11 p_ P11 I I ._._.

III. GENERAL CONTRACTOR

11. Na Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name- ( E'e _(_ _ _ _1_,CO _ _ _ _ _ _ _ _ ____ ----- _13. Contact Person _ ~ L_J✓L/~ _

14. Federal Employer ID. # P h- 1 . Tel. # 516 - 2~r - 3 4 6 0 Fax # c

16. Address ~lv 1'!~ --__--- City ! ~ 3L_ State /U Zip

V. THIRD PARTY AIR MONITOR

17. Name v_1 9 _ > ZEtZ j l( r!It ~Sp≤—_18. Contact Person _ tE L (^

19. Federal Employer ID. # 20. Tel. # QJ=~aa P — Fax # I~=_~~~=GAO

21. Address g [_ !=f~ _//-- City `€1"~ State Zip 100 (-

22. Sample Analysis Laboratory___ - (f 17 « 4_ ~-A ~''r'«5 tt,- — 23. NYS DOH ELAP # _ t 2.__-_

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

Asbestos work schedule ❑ Monday 0 Tuesday ❑ Wednesday ❑ Thursday ❑ 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 35 — Square Feet, and/or _--- Linear Feet 7 Oi SES Si AiB:Y i E1~_f`` 4;dF.l.~3 Kh7

NYC-WTC 000111193