Asbestos Project Notification Form, Corona NY

NYC 9/11 Public Portal Document

1 caror.,A, NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ~`.°". . *. Asbestos Control Program 59-17 Junction Boulevard. 8th Floor, Corona, NY 11368-5107 — -- .

ONLY D ~ ~ fOR OFFOIAL SE ONLvo TYPEWRITTEN cnMrnraoa°~cc~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE - (ASBESTOS INSPECTION REPORT) 1 --- -_ ACCEPTED .,.,. ^rc.:e"1'°r • (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 G~ Q 2. Address _~~_ l — D t-O A b VJ A "~—___--«_ Borough N _ Zip

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

5. Type of Facility -- -----6. Name of Building

II. BUILDING OWNER I I

7. Name ~--=c fl~~~ -I--~~1 DD~ 8. Contact Person~~(Jf~TG ' ._._._._._._._._._._._._._._

9. Tel. tlo~~ a ~-a = 93 Fax # -------------1 10. Address _ ~L_U L S i t _ City ~~+ ' State ~ Zip _LQ~

III. GENERAL CONTRACTOR

11. Name_—_-_______ Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ( ell ( .—____ _----__13. Contact Person

14. Federal Employer ID. # _.-.-__.~PII.___ 15. Tel. # l 3060 — Fax # cC 16. Address oc v v~_______ city JP IL ____ state / zip _LLZ V. THIRD PARTY AIR MONITOR , 17. Name -~~ ~ ZED_ G / ^~~-'~1 18. Contact Person 19. Federal Employer ID. # P 11 20. Tel. # a 1 =~aa =d Fax # ~O

21. Address ~~ fZ_ _ City ' `~ _--_ State L~ Zip L00 (_ 22. Sample Analysis Laboratory_ l ( (( ~~- h ~- I _ 23. NYS DOH ELAP # _i_L iL___

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

I Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday 0 Friday 0 Saturday ❑ Sunday

Shift from: ❑ am ❑ 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

4Z Square Feet, and/or Linear Feet '7 01 e7PdAJ 7r f~.P^• :Y~l~Tbl 4Eb:`f:-iiw S C`,rvCOy hT 4101-.1S Cr:.7R0l• P6CSPAM ron)

NYC-WTC 000111208