Asbestos Project Notification form, Corona NY

NYC 9/11 Public Portal Document

02 b ~TC. NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard, 8' Boor. Corona, NY 11368-5107 Building Dept or TRU No ONLY I~ FOR OFFICIAL USE ONLY TYPEWRITTEN ' r~ ~ ASBESTOS PROJECT NOTIFICATION FORMS WILL B (ASBESTOS INSPECTION REPORT) 1. See fee dledule) -

I 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 I 1 S > _OM Borough 'f Zip f O b b AKA 3. Block 4. Lot

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

II. BUILDING OWNER

7. Name C-'EI.L 1 UU J L1 11 1 C- 8. Contact Person

9. Tel. #( -7- Fax # `. 10. Address .j !7~ ~~ _ City ~`~ — StateN Zip -/ 00 ~3v Ill. GENERAL CONTRACTOR

11. Name ___________ Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name -------- _.13. Contact Person _ J ~x _ L/9

14. Federal Employer ID. # P11 ~16- 7~1'3000 15. Tel. # ---__-- 516- ?d/-3d~5 Fax _--__— 16. Address o1 L2 )S-.AL - - City ) / ~/ _ State N Zip ILZ -?

V. THIRD PARTY Al? MONITOR I 17. Name Z _ A'r(ZE2 NCii ~f S F PC 18. Contact Person

19. Federal Employer ID. # _---_ 20. Tel. # a ( =jaa - oOf t— Fax # La a ' O 30

21. Address ~~ g 1 1 r City ~' 12 I _ State N Zip L 00 ( . / 22. Sample Analysis Laboratory_ _c .1_((t;F«- L *6 t !L `' c 23. NYS DOH ELAP # _ / ( t2

VI. PROJECT INFORMATION / 20o Z. 24_ Starting date for this portion of work -b i 8/ C 2 Projected completion date _J_ 1 t/

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

Shift from: 0 am 0 pm to 0 am ❑ pm

If other, specify ~EOVED Access to inspect the premises must be provided during the work schedule indicated in this item. JUN LO 1? 2002 25. Total amount of asbestos-containing material to be abated during this work O 39 ' 7 ' Square Feet, and/or Linear Feet ACP' ffi c 2!200 E~'J?rA'18f E 412.::C'wTI r.•tP:;•;I.~t.TAL

PRf II LI tR~l

NYC-WTC 000111210