Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program L Il k a1' ► DP 59-17 Junction Boulevard, 8' Floor, Corona, NY 11368-5107

ASBESTOS PROJECT NOTIFICATION Building Dept. or TJ No FOR OFFICIAL USE oliv EWRITTEN no R FORMS WILL BE` ACCEPTED wru d (ASBESTOS INSPECTION REPORT)

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 __L2 5 FULTO N smw2 eT — Borough Zip

AKA —__-- —_ 3. Block 4. Lot

5. Type of Facility_---- 6. Name of Building _

II. BUILDING OWNER

7. Name A.*~ RL'r`>' -----_--- 8. Contact Person 4V QG a D i M ov —

9. Tel. # C-ti8) T2G - -T'r Ott — Fax # _---

10. Address _ t_ VOLToA -- City -- N`1 ------r State _ u`i _ Zip

Ill. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR IAnIN t Co —- 12. Name -u rw~ iQ2Ea.W A ±— t 13. Contact Person _~utE

14. Federal Employer ID. # _----,_ --___ 15. Tel. # £!!1 531 .22L._ Fax # c2t8) tog _ I808 _

16. Address J14 4_ J .---______ City BRook~'~ N —_ State iL— Zip _ (,L_236

V. THIRD PARTY AIR MONITOR

17. Name ~''~ PAWZtcR 4EA6rtJEEeS 1Nc --_18. Contact Person _! ICt>lAE~ IJo~t►n1 ---

19. Federal Employer ID. # ------------- 20. Tel. # - Oø3_ Fax # 212 22 - 0630

21. Address 2213 —EAST 45111 STRrEt=1"-- - City — IJ'. -----_ State N4 _ Zip _ 1O9IT —_

22. Sample Analysis Laboratory—__~ ___—r---------- 23. NYS DOH ELAP # _----___

VI. PROJECT INFORMATION 24. Starting date for this portion of work 'C6' 20 0_ _ Projected completion date —~? I 2-

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

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 CPROGR

Square Feet, and/or _2 LinearFeet ACP 7 2/2001

POU?PSIRO(

NYC-WTC 000111291