Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

Eo1 ~~ ,~OQC~. ►v: •yI NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard. 8 Floor, Corona, NY 11368-5107 O 4 ..J L?rEN \ .DP d~ ASBESTOS PROJECT NOTIFICATION Building Dept. or TRU No FOR OFFICUL USE ONLY

Mft ruiioe°c ILL BE (ASBESTOS INSPECTION REPORT) 1 PTEDI ;• ; ;rc $ .Ids.. fee schedule) J 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 _-3 DUTCt.( ST ET Y — Borough — u 1' — Zip _— --

AKA — T Ill Cw u ST'MC- -r _-- -- 3. Block --- 4. Lot 2(D ___-

5. Type of Facility_....g PE}JI1 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----------------------- -------- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR ~1 12. Name B 4k fit l/.t —IeUt`Z AM 4 SOW 0,0012GL I t4C _13. Contact Person _---__------__-

PI I C'tl8) 531^2~Uo 14. Federal Employer ID. # _ 15. Tel. # — Fax

16. Address __L2AB_ t-f'~I A~ E~1~`-E — City 11__ State ?! y Zip _ 111236

V. THIRD PARTY AIR MONITOR

17. Name l Ret2EtJ PA11Z.~ Eluc-, 1 13 1ZS- _----- _18. Contact Person M1Cfl t IJot-at3 [------------P11 `_ 20. Tel. # -117 — Fax # _121? I c Xg Q '2 0 - 19. Federal Employer ID. #

21. Address 22R ~h sr AS't1.1 S -t_R zr -- City '1c>0--w- _ State _u4 _ Zip _ lP 1 _

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

VI. PROJECT INFORMATION 24. Starting date for this portion of work ~O 4f 2 Projected completion date

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

Shift from: _____ ❑ am ❑ pm to — ❑ am 0 pm 6 If other, specify ----------- - 7...; Access to inspect the premises must be provided during the work schedule indicated in this item. r. ? 002 _ t,' 25. Total amount of asbestos-containing material to be abated during this work .

Square Feet, and/or — Linear Feet

DI M001

NYC-WTC 000111301