Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

00f ETC NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard, 8 Floor, Corona, NY 11368-5107 Building Dept. or TRU M ONLY ~ ~I FOR OFFICIAL USE ONLY

ASBESTOS PROJECT NOTIFICATION h%1S>~ IVLL BE 'oir"-`°jeR (ASBESTOS INSPECTION REPORT) 1. 1~'A~CE'P?ED +_nyc for/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 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 _ i 6 N A5 S AU _ 1 2 T Borough — -- Zip

AKA —__ A S A.NN S_ EE'T'—_ `---- _ - -_ 3. Block 4. Lot

5. Type of Facility_ CtiM gt~CA a L --------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_~t-Eh1i ,4h +1~Ktl~R A m SAN Cara} -------- Tel. # ---__--

IV. ASBESTOS ABATEMENT CONTRACTOR ,t 12. Name _BE1J~AM 1 N {_u 122 BAtA 5 5oN Cu1._T1zo1_ - -_13. Contact Person _Lau►e__ ANN ►Co

P11 14. Federal Employer ID. #j ........................................ L 15. Tel. # C118) 5 3i _'R9C9_ — Fax # C]!R)_ 209- f $O8 ___

16. Address 12 4 i3R.s4~-P A\►Et~►~3 E ------ City 21t~-Y N —_ State _ ±t _ Zip _ I i 2 3 C— _

V. THIRD PARTY AIR MONITOR

17. Name > R- &* 2 FI - _18. Contact Person ~ItL~ N CL a1J ---

19. Federal Employer ID. # ~, PI,I _ -~ 20. Tel. # C _— 922 -~91 --__--_— Fax # Lz~2) 922 _- o6 30 --_

21. Address 2 2 S —EAST `!STO ST --- City __~1aL 1/ 2 _ ___ State N 4 Zip _L 0911-

22. Sample Analysis Laboratory..._._.______...__........- ------------- 23. NYS DOH ELAP #

VI. PROJECT INFORMATION C 24. Starting date for this portion of work _O~ / Cv2 Projected completion date —7_L j_D_L

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

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

If other, ~rc ` specify -------------- . t/,lc tL~ n U Access to inspect the premises must be provided during the work schedule indicated in this item. : J J N +7 7 2002 25. Total amount of asbestos-containing material to be abated during this work , ~.

. > 57 L__ Square Feet, and/or _. ..2 Linear Feet '~ <

t.1. lnl 2

NYC-WTC 000111289