Asbestos Project Notification form, Corona NY

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program p 59-17 Junction Boulevard, 8'" Floor, Corona, NY 11368-5107 — Building Oept. or TRU No ONLY D ~1 FOR OFFICIAL USE ONLY

TYPEWRITTEN ~~~MrNru- °R~` ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED " "r` s°•J"' (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

_l.~___ v 2. Address _L^-~ -Vo4 tzWA ---------- Borough _N _L_ Zip _L22!1 3. Block _--- 4. Lot

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

II. BUILDING OWNER

Name E f~ j~ a- — _— 8. Contact Person

9. Tel. # (9-1 oZ-~o 7_ 1-7 7'2 Fax # ___________ - 10. Address L iL—moo fJ _—S ---- City -- `~+~ ~L--- ______ State 1 " ~ Zip _--_ —.

III. GENERAL CONTRACTOR

11. Name------------------------------ ------ ---- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _ (~el~ (' 3~ ---------- _13. Contact Person _~ ~ __~✓~1_

14. Federal Employer ID. —_ # . _x PII __ .x_ 15. Tel. # l_ 6 -__ — 7~~ -3060 ---____— — Fax # _ c~I _t_ -2J6 3cct5 _ ' ,d 16. Address _3ol~(~ 1 /_J! — --City J / ~/ _--_ State /S! Zip _LL22 _

V. THIRD PARTY AIR MONITOR

17. Name ,{ V; ) ~ Z~~ +r JS+ ~c -- _18. Contact Person

19. Federal Employer ID. #1 _ -- -L 20. Tel. # Q_~ dQ — Fax # I 2 g D _

21. Address g L__ i>c City _CL€1`~ ~ ---_ State L-_ Zip 1L! . ____

22. Sample Analysis Laboratory—__~4( f « ~^*6 C ?-A '1 J — 23. NYS DOH ELAP # _ L L

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 _--- ❑ 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

32~Q2_ Square Feet, and/or _—_—~ Linear Feet '7 31 III;NA'i N' 9 4EL:S.;.JKY SI:IR1:atA7A Etir;)fCfiIE7,T 4 sr,J3 Cn.JJRCL PACCR;m Jrny

NYC-WTC 000111213