Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

o33wIC~ NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard, 801 Floor, Corona, NY 11368-5107 — Building UepL or ii' llkek FOR OFFIOAL USE ..... f on°` ASBESTOS PROJECT NOTIFICATION L. N ~~ MS WILL BE (ASBESTOS INSPECTION REPORT) 1 ACCEPTED

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 14_ U6 Fyca - 01J S-r¢~.r—T Borough Zip

AKA 3. Block 4. Lot

5. Type of Facility___---__— 6. Name of Building

II. BUILDING OWNER

7. Name — 8. Contact Person

9. Tel. # (•2!2) TS2 - t653_,__ Fax # ----

10. Address =o V~ SS EY S -rRa T — City —-9 —__~ State _! _ Zip _----«

III. GENERAL CONTRACTOR

11. Name_N -- -----_ — — Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name T3(~n11 A M 1n1 KuRz.BA1.1 i SON ~ic1J'f1ZOL I NC 13. Contact Person _ Lou(E —I14N Nt C.0 ---

14. Federal Employer ID. # _---- ---_— 15. Tel. # ~~!$~_ 53t-2900 Fax #

16. Address 12 — City d'2 --« State JL. Zip J.!2'

V. THIRD PARTY AIR MONITOR N0L.IkO 17. Name A)AP 4 PAN eQG (0e- E" ( -tomN -18. Contact Person ~1iC Aet,

19. Federal Employer ID. # _____------ 20. Tel. # C2 r2) 922 -4 E7T-- Fax

21. Address 226 E3~£rr4-STtlSTMAE E ---- City __ NY ------ _State _!tL_ Zip _ 100IT

22. Sample Analysis Laboratory—__---~__--- --- — 23. NYS DOH ELAP # — _____—

VI. PROJECT INFORMATION , 24 Starting date for this portion of work ° _ Projected completion date /1L.2.. Asbestos work schedule ❑ Monday ❑ Tuesday 0 Wednesday ❑ Thursday ❑ Friday 0 Saturday 0 Sunday

5 Shift from: __ 0 am ❑ pm to --- 0 am ❑ pm 6 4 ~ If other, p 0.,~ V r0 specify --- - "((,}.~ G Access to inspect the premises must be provided during die work schedule indicated in this item. j JUN 1S 2002 N Co 88E8TANHM 25. Total amount of asbestos-containing material to be abated during this work pSTOAMAG TRU 13 32.1' Square Feet, and/or _— Linear Feet 2 G ACP 7 11 1\ 212001 8':RF.AUtJOOF £IiV RONM NTAi

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NYC-WTC 000111295