Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

Eo1 Lio77: 0.ClT fr NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard. 811 Floor, Corona, NY 11368-5107 o K F.D:.P ASBESTOS PROJECT NOTIFICATION Building Dept. or TRU No FOR OFFICIAL USE ONLY

Q)AWILL BE "Onu(Nrwii~~°c (ASBESTOS INSPECTION REPORT) PIED ;• ; ;rc i Idr.. schedule) Z 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 ST ET Y - Borough - u N - Zip _- -- 2. Address __ 1_.P AKA T Ill 2I ST N —_ 3. Block -- 4. Lot 2l0

5. Type of Facility_....g PE}J'T t 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------------------ Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR ~1 12. Name B 4k M I —{ t`Z AM 4_ ±L (?,0012GL I NC _13. Contact Person _---__------__-

14. Federal Employer ID. # 4_ PII 15. Tel. # C'tl8) 531^2 U0 — Fax

16. Address I2~ _ ~ ('~) Aq E .)oke — City -- State _Ij_ Zip _ 11236

V. THIRD PARTY AIR MONITOR

17. Name _ Ai=¢E1J_ J'PA1.1't.~~.. EI.,C-, t 1GEE S__----- _18. Contact Person q ( Ct1 Ael— ~Ot.aO 0 _ 19. Federal Employer I0. # _ PII `_ 20. Tel. # .1 2i.)2 !..L_ Fax # _12 21 '22_O63

21. Address ??R ~h _r AS'Tl.t StR zr -- City ~Q - _ State _u4 _ Zip _ lPD1T

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

VI. PROJECT INFORMATION 24. Starting date for this portion of work Projected completion date

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

I Shift from: __—___ ❑ am ❑ pm to — ❑ am ❑ pm ~ L 6.'

If other, specify ---------- ------------------ - RECEIVED Access to inspect the premises must be provided during the work schedule indicated in this item. JUN 21 2002 'Co ''BANHt.' 25. Total amount of asbestos-containing material to be abated during this work ';!GSrli:;. I- GRAM 1U _ 1_4 5 __ Square Feet, and/or _—_--- Linear Feet ci ; rt \fit. ACP 7 2/2001

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NYC-WTC 000111301