NYC 9/11 Public Portal Document
NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
Asbestos Control Program
D~ I p 59-17 Junction Boulevard, 80 Floor, Corona. NY 11368-5107
Building Dept. or TRU No
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ONLY t>~ FOR OFFICIAL USE ONLY
TYPEWRITTEN ASBESTOS PROJECT NOTIFICATION
FORMS WILL BE f'~~NM~Nru:~n~`°±
- (ASBESTOS INSPECTION REPORT)
ACCEPTED " ^y :'•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
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2. Address E LIB ~ Borough y1 1 -- Zip 0 0 (
AKA -------------------------- -- 3. Block ------ 4. Lot -------
5. Type of Facility — 6. Name of Building ---
II. BUILDING OWNER
7. Name —_ 8. Contact Person
9. Tel. #
. ......-.-.-.-.-.-.-.-._.-._.-.... -.-.-.-. .-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.... -.-.-.-.-.-.-.-.-.-.-.-.-.-.... -.-.-.-.-.-.-.
10. Address; P11 L_ State -! Zip _I1_
Ill. GENERAL CONTRACTOR
11. Name_--__ -- Tel. # -----
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name ( C'll - -c v`'.-- U ! ----_13. Contact Person ~ _~~ L/
----`
14. Federal Employer ID. # ! P11 15. Tel. # c~ 1 - 7~r 34 60 — Fax # _ c cJI 7/ cs
16. Address ~ q C~ `~--__--- City —__ / --_ State /U Zip 1L2 _
V. THIRD PARTY AIR MONITOR
17. Name y ~~ h7'(Z~ 2 G i~k~~S 18. Contact Person _--________-------
19. Federal Employer ID. # 20. Tel. # J Jaa =00 — Fax # I=_~~~=G& O _
`_~
21. Address g L ~'S!=f~ --- City CL`€b`~ State Zip 100 (
22. Sample Analysis Laboratory____ (tomf ( « G=*6a r -a~~`r'ie5 c 23. NYS DOH ELAP
VI. PROJECT INFORMATION
24.. Starting date for this portion of work - Projected completion date ----______-
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Asbestos work schedule ❑ Monday 0 Tuesday ❑ Wednesday ❑ Thursday ❑ Fri
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
3 515 — Square Feet, and/or _---~ Linear Feet
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01
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NYC-WTC 000111193
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