Asbestos Project Notification form, Corona NY

NYC 9/11 Public Portal Document

OP1. qr NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION '~h. Asbestos Control Program ■~ 59-17 Junction Boulevard, 8"' Floor, Corona, NY 11368-5107 ONLY D A Building Dept. or TRU No FOR OFFICIAL USE ONLY TYPEWRITTEN r ~"~oNM~N rw vaon°°er ASBESTOS PROJECT NOTIFICATION 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 NYCOEP 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 _LT Borough iJ_ - (.-- Zip

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

5. Type of Facility, 6. Name of Building

II. BUILDING OWNER

7. Name -Ct 1~; UL -- Pry- _ -IJ —_ 8. Contact

9. Tel. # (a-i P-6 ~_ -1-7 7O Fax # ------------- 10. Address ~lEci-'-1~ S L City

Ill. GENERAL CONTRACTOR

11.

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _rk1E'IL C 11 0 13. Conta. QCu(\ 14. Federal Employer 10, # _L . . P! 1 15. Tel. # J 6 ' 7~L 306 16. Address o1c ; v~ V~_--_ -- City t'.J /2L/

V. THIRD PARTY AIR MONITOR

17. Name ~_yL L _ A"►'t Z~2 G I4T~S fC 18. Contact Person

19. Federal Employer ID. # .~,._._._,_._. _P 11 _ 20. Tel. # «=1aa =04 — Fax# Ic~_ O -

21. Address L S` r {~ __— City L`L€1`~ —__—_ State t- ~_ Zip

22. Sample Analysis Laboratory—_ _ ( I ~G~^ *6 a r"A f `e- u c — 23. NYS DOH ELAP # _ —_

VI. PROJECT INFORMATION 24..Starting date for this portion of work Projected completion date r, r-i Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Frii

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

3$ Square Feet, and/or _—_—, Linear Feet 7 '1EP 5'1^EAU or ENYIR39;1EI~MAL :if.' S Ee,h, .:,EE '.Ms J:RCL7CEi,1EAT rRCCRAld roll 7

NYC-WTC 000111212