Asbestos Project Notification form, Corona NY

NYC 9/11 Public Portal Document

/0 ( W TC...... ;,,,~, NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program . rtI1&Arw 59-17 Junction Boulevard, 8e Floor, Corona, NY 11368-5107 Building Dept. or TRU No FOR OFFICIAL USE ONLY NL 1T"'~

O E aruiirton~c ww nra~or fact, ASBESTOS PROJECT NOTIFICATION (ASBESTOS INSPECTION REPORT) 1,

When submitting this form at the NYC Department of Buildings, the original form and three (3) copies with original fee schedule)

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 _L2__ ? W AV — ----- M---- __ Borough __M_ .__ Zip

AKA -- 2 ouN— S-cREE T_--------- ------ 3. Block -- 65 -- 4. Lot L.____

Type of Facility___ COMMEeGA►_---- ----- 6. Name of Building ----------- -----__—

II. BUILDING OWNER

7. Name _E*oINAM rx+ 5 ------------------ 8. Contact Person RAC lht MAtn—_

9. Tel. # _--____---_---__ Fax #

10. Address --------------- City State _____ Zip -

III. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name u __--- _13. Contact Person _Lnvt—(ww►+~c __-- .-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.. 14. Federal Employer ID. # PII 15. Tel. # t ~tB~13L222....__ Fax # (] =!80&_____

AVL~1Sl1E — City __L~''r_'s____--_ State N't' Zip _Il ? 36 16. Address _ 12413 _ Rs~PN

V. THIRD PARTY AIR MONITOR

YEU fi "PhP z—cm I N c~~¢__~`.— l nsr_—__- -_18. Contact Person 0 ---- 17. Name L0494

19. Federal Employer ID. # _- _--- _--P11_- _-- _--. _ 20. Tel. # _(_i!12 27 IL.___ Fax # t2t2 )_ 927_ c'63'0 _—_ - act

21. Address _ 2 2 8 Eis: 4 sT►t _STR-rcT ----- City Nom%' Y~ ____--_ State _L. Zip _. _T___

22. Sample Analysis Laboratory, 23. NYS DOH ELAP #

VI. PROJECT INFORMATION ) 24.. Starting date for this portion of work __7I LJ/ _ Projected completion date __!—~) / ° Asbestos work schedule IT Monday ® Tuesday I Wednesday ® Thursday I Friday I Saturday ® Sunday

l'1■1M Shift from: _ — m am 0 pm to __i 0 am ® pm

If other, specify ---------------------------- --------------- REc NED Access to inspect the premises must be provided during the work schedule indicated in this item. )i.i (. 1 7 2002 -'O'BANHr' =~i:STOS/L~:= 25. Total amount of asbestos-containing material to be abated during this work P:CGRAM TRUG 2S 22T __ Square Feet, and/or _---n Linear Feet ACP .• tip 2/200 ..•r~t~~1

NYC-WTC 000111251