Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

/O/ aN tir o[ry, NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION 0 --a '~~, • Asbestos Control Program 59 17 Junction Boulevard, 8'" Floor, Corona, NY 11368-5107 Building pt. or TRU ~o FOR OFFICIAL USE ONLY RITTEN ~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE ru (ASBESTOS INSPECTION REPORT) 1 ACCEPTED j "v$ • e 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

2. Address I14=116 F UL'TON— STREET — ----__ Borough —M N Zip

AKA 3. Block 4. Lot

5. Type of Facility 6. Name of Building

II. BUILDING OWNER

Nme _ C EOAR 7. Name M AN A6 M E N i—_ _ — .___— ---_ 8. Contact Person W ------

9. Tel. # _ (2 12)_7 3 2 = 2653 Fax # - -----------

V ESEu STR EEr --- City --- N —tfo Rk —_ State _±L_ Zip 10. Address _ 20

Ill. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name 3es..s^Mtta kuR2(3A.N 4 SOO Com r2Ou. —_13. Contact Person

14. Federal Employer ID. # PII -- 15. Tel. # - Czt$) 53L229____ - Fax # _ CZI 8~?91 FsoB __—_ ._._._._._._._._._._._._._._._._.~ t - 16. Address .J2_4 _ RALP►1 Aven)UE __---__-- City __gecog-L-9 N_ —_ State NY__ Zip __12236 _

V. THIRD PARTY AIR MONITOR

18. Contact Person --- 17. Name Ek1At2QEW~ pA1J'ZEC ENS LN ---------

19. Federal Employer 10. # ,_._._._._._._.P 11 -_ 20. Tel. # C212) 922-o913__ Fax #

21. Address _ Z?8 EAST 45 Ttit S~TZE cr ---- City —~) ---_---_ ------- - State N i _ Zip - 10017-- _

22. Sample Analysis Laboratory_------------------------- 23. NYS DOH ELAP #

VI. PROJECT INFORMATION 24.. Starting date for this portion of work _ OG ~ 23 i 0 2 Projected completion date

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

Shift from: IC! am ❑ pm to 8 ❑ am I, pm

If other, specify ------------------------------------------ - ' &o Access to inspect the premises must be provided during the work schedule indicated in this item. JUN 2 7 2002 _. ~~B4NN~o 25. Total amount of asbestos-containing material to be abated during this work !! ..RTOSIL .. V

___ q41( — Square Feet. and/or r—~— Linear Feet ! 01 G, ACP 21200

NYC-WTC 000111271