Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

-E o 3T 0 NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard, 61" Floor, Corona, NY 11368-5107 Cr TRU No ONLY ; USE ONLY

TYPE EN hrAirilon° ASBESTOS PROJECT NOTIFICATION F 1 BE (ASBESTOS INSPECTION REPORT) 1. (See fee

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 wy 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 .L~ -1 ~ ~~1 At i Borough Zip / 8"A 2

AKA 3. Block 4. Lot

Type of Facility, 6. Name of Building

II. BUILDING OWNER

7. Name S ~ F4-*~~G~~ t Contact Person ~a (D I

9. Tel. #1 -f -) - 22L( i ax #

10. Address —S T _—_ City _._&. _ State L JZip

Ill. GENERAL CONTRACTOR

11. Name__------- - -________ — Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name PeIe — — ------- — 13. Contact Person _~ S~L ____

14. Federal Employer ID. # P '15. Tel. # c~ - 7~ -- 300 0 Fax #

16. Address o12Ai?~. — City I l~ - State /L Zip IL?_

V. THIRD PARTY AIR MONITOR

17. Name v 11 ~ k7(ZE2 .1~a1 ~T S~ PC_18. Contact Person !uL ,~ r ~' `~("

19. Federal Employer ID. # 20. Tel. # ' ( aa - O l— Fax # 0

21. Address I —//_ City ~' State _ Zip (00

22. Sample Analysis Laboratory— SC/ f /~(L t%~ *6 9 r lES A_tt 23. NYS DOH ELAP # _ L r/ 7 oG cJ

VI. PROJECT INFORMATION 24.. Starting date for this portion of work __6/19 _ '_ Projected completion date --.h i1_200 2_ Asbestos work schedule 0 Monday 0 Tuesday 0 Wednesday 0 Thursday 0 Friday ❑ Saturday 0 Sunday

Shift from: ❑ am ❑ pm to ❑ am ❑ pm

If other. 4 specify RFCEIVEC Lfl Access to inspect the premises must be provided during the work schedule indicated in this item. JUN 1 7 2002 CEP,BANu! 25. Total amount of asbestos-containing material to be abated during this work ASBESOS'- /~ FRC'uP- •. 0 Square Feet, and/or Linear Feet TnU:

ACP 11 2200 C7°~AY 1' E'1LP?•'^~cR^AL 4:t::i IF•7 3 ;`,r fi4E1,T Pfif,,;a;,Ll Ipn

NYC-WTC 000111205