Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

CITY ~. NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION 0EPupi, F Asbestos Control Program 0W` 59-17 Junction Boulevard, 8th Floor, Corona, NY 11368-5107 ONLY D1A.IP ASBESTOS PROJECT NOTIFICATION Building Dept. or TRU No FOR OFFICIAL USE ONLY TYPEWRITTEN 11 roNMENrwvaen~oo' FORMS WILL BE (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 ~9 D 2. Address {'~ ~~ S) 1—SI✓ ` Borough — Zip

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

5. Type of Facility —__--- 6. Name of Building ---_-

1I. BUILDING OWNER ,~p,.~ 7. Name Yft lLxs L~2t~— —~~ 1f'!-Y1 ^rE ~ f _-- 9. Tel. #ka-~ _~-~~ Fax # _ ------------

10. Address _l ~ --f---- ~~ S City ----- --------- `~ III. GENERAL CONTRACTOR

11. Name------------------------------------ —~ — IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name AIL -------- _13 x(

14. Federal Employer 10. # _._._._._r....._._._._._._._._.!15. Tel.# _i i 2L ? _

16. Address old (~ ~_--__— City

V. THIRD PARTY AIR MONITOR

17. Name ~ k 18. Contact Person —_-

19. Federal Employer ID. # —______--___ 20. Tel. # _Q Fax #

21. Address g >6_[_4 ~r --- City _t ^_ __--_ State _ Zip _L00 ( L - 22. Sample Analysis Laboratory__~~ ( Il^ ~- 9!L1 tr — 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 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

sd — Square Feet, and/or --- Linear Feet 7 )1 S E},r ^CE.t:h7 cS-_. dS C('76RGl retry

NYC-WTC 000111202