Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

04 k) / e. DEPARTMENT OF ENVIRONMENTAL PROTECTION

DEC Asbestos Control Program 59-17 Junction Boulevard, 8 Floor, Corona, NY 11368-5107 O' //iiJa Building Dept. or TRU No ONL FOR OFFICIAL USE ONLY TYPY ASBESTOS PROJECT NOTIFICATION ee f' ~ (ASBESTOS INSPECTION REPORT) I

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 4 7 Ann St Borough Manhattan Zip AKA 3. Block 92 4. Lot 17 5. Type of Facility 6. Name of Building II. BUILDING OWNER

7. Name — 4 7 Ann S i`A,69 C i a e s LLC _ 8. Contact Person 9.Tel.# (212) 706-3030 Fax#

10. Address __ City State Zip III. GENERAL CONTRACTOR

11. Name --_ Tel. # —_ IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name Benjamin Kurzban & Son Control ___13. Contact Person Louie lannioo _ —~

14. Federal Employer ID. #'_._._._. 15. Tel. # (718)_531-2900 __ Fax # (718) 209-1808 248 Ralph Avenue 16. Address 1 City Brooklyn State NY Zip _11236 V. THIRD PARTY AIR MONITOR

17. Name Warren & Panza _ 18. Contact Person 19. Federal Employer 1O. # L._._._._._._PII -_ 20. Tel. # (212) 922-0077 Fax # (212) 922-0630 _N-- 21. Address 228 East 45th St City New York State NY Zip 10017 Y 22. Sample Analysis Laboratory 23. NYS DOH ELAP # VI. PROJECT INFORMATION 24. Starting date for this portion of work _ v1? Z I 0 2- Projected completion date

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

Shift from: ❑ am ❑ pm to _—_— 0 am 0 pm ~C If other, ,r specify ------- -- -- _— Access to inspect the premises must be provided during the work schedule indicated in this item. / J~' '

` J~ p 1fJE ~•- p N 092 25. Total amount of asbestos-containing material to be abated during this work co "-\ 46 45 $Square Feet, and/or 0 Linear Feet ' '

2R001

4tp 91%'Et'U Of EVAP."~7l/E" P.£M1tiglio, 6 eIr CEf✓iE. A-at$ ~iS CONTROL p N TR11

NYC-WTC 000111297