Asbestos project notification form, Zone I Originals

NYC 9/11 Public Portal Document

„Y~rA 1 NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION "~' SAN. Asbestos Control Program 59-17 Junction Boulevard, 8th Floor. Corona, NY 11368-5107 Building Oept. or TRU No ONLY DxP FOR OFFICIAL USE ONLY TYPEWRITTEN rw:~~° ASBESTOS PROJECT NOTIFICATION FORMS WILL BE - (ASBESTOS INSPECTION REPORT) 1. 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 _lf- C ► Borough —N-- Zip

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

5. Type of Facility 6. Name of Bui;ding II. BUILDING OWNER

7. Name E ~ g i-- &ioi ( ~ 8. Contact Person -

^7 2-- a~7 9. Tel. # fD~~Fax # -------------

10. Address ~C7 ~ ~t {~"~ 1__T_ __SL City --- —___ State N ' Zip

III. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name L~~IL ( 1O ----- __— __--- _13. Contact Person ~ C 14. Federal Employer ID. # P 11 ._._._._._._._._._._._._._._._._._._._._._._ 15. Tel. # c1 7~ ~ ----— ---------- O Fax # c~~ ~ --- ~d~s --------- 16. Address City —____-- State L Zip _LL223L V. THIRD PARTY AIR MONITOR

17. Name IQ _ 14 rt Zc 2 G i r /,try S+pC 18. Contact Person

19. Federal Employer ID. # P 11 r__ 20. Tel. # Fax #

21. Address ' r City t State Zip g L --- cJ~--_ 22. Sample Analysis Laboratory ( ( is ~- A °~-'f £5 23. NYS DOH ELAP # _L LB _- _

VI. PROJECT INFORMATION r 24.. Starting date for this portion of work _ I rn- Projected completion date r-~ r_1 Asbestos work schedule 0 Monday 0 Tuesday 0 Wednesday 0 Thursday 0 Fri

Shift from: __—_— 0 am 0 pm to _--- 0 am 0 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

1_Q_.O_. Square Feet, and/or _—_--- Linear Feet 7

Pn a;tl trf."7

NYC-WTC 000111198