Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

• ' oo T ~ NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ~rtr oto~+Pr Asbestos Control Program 59-17 Junction Boulevard, 8 Floor, Corona, NY 11368-5107 Building Dept. or TRU M ONLY ~\ ~~ AI FOR OFFICIAL USE ONLY 'AONMr ASBESTOS PROJECT NOTIFICATION A1S>~BE "~"`°jeR ((ASBESTOS INSPECTION REPORT) 1. ~~1l~CEPfED _...1".115 /or/aep fee

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 6 N A55 AU - S•- 'f- — —_~ Borough — -- Zip

AKA _A5_ ± — !ZEE? —_ `---- _ - -_ 3. Block 4. Lot

5. Type of Facility_C -m mEizC.t a ------- 6. Name of Building

II. BUILDING OWNER

7. Name 8. Contact Person

9. Tel. # _------------ Fax #

10. Address City State __ Zip _-----_

III. GENERAL CONTRACTOR

11. Name_G-ef h +1~ K N # Sa+a Cara} -------- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _BE11~AM I A k1/ 22.BAt1 5oN CutiTQcl_- -_13. Contact Person _Lou ►e__ a!w M ► Co____— ----------------------------------------, 14. Federal Employer ID. # j PI1 L 15. Tel. # _ _ :_L° 29__ Fax # C2!8)?09- 1'908

16. Address _ i? 4 $ —fL& ± EN? E ------City P~c1[s ~c N —_ State — N f _ Zip

V. THIRD PARTY AIR MONITOR

17. Name A4 -E - PA 2 -~ - -----_18. Contact Person ~~tt~ N c !w ----

19. Federal Employer ID. # ,__ _ _---, 20. Tel. # L12 922 ~?92Z__— Fax # j 3d ___

21. Address 22$ AST .4ST14 ST — City ~1 J9±___.. State _k' _ Zip

22. Sample Analysis Laboratory 23. NYS DOH ELAP #

VI. PROJECT INFORMATION 24. Starting date for this portion of work _ LP _ L2 / v2 Projected completion date

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

Shift from: __—___ ❑ am ❑ pm to _— _ ❑ am ❑ pm

If other, /N>' '6 specify -------------- -- ~ftt! FLU Access to inspect the premises must be provided during the work schedule indicated in this item. ; : JUN 0 ?p02 p '3APJH/~ 25. Total amount of asbestos-containing material to be abated during this work ' ~'OS,' ~.

) LL._ Square Feet, and/or ....._.2..... Linear Feet ' < +Ic?. ~T7I ACP; 2/200' .4, ;; .i ,~` ln~l 2

NYC-WTC 000111289