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Asbestos Project Notification Form, DEP Box 39

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NYC DEP form for notifying the department of an asbestos inspection project at a facility.

NYC-WTC_000111279–000111302

Folder label: “Zone II Originals

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NYC 9/11 Public Portal Document gow NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION O ei) Asbestos Control Program §9-17 Junction Boutevard, 8 Floor, Corona, NY 11368-5107 ASBESTOS PROJECT NOTIFICATION ONLY ‘ TYE ~ NE (ASBESTOS INSPECTION REPORT) 4, 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 NYCOEP 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 . 4& O49b1 Yor Building Dept. or TRU No FOR OFFICIAL USE ONLY ( fee schedule) 1. FACILITY 2. Address 122 Nassau Street Borough Manhattan Zip AKA 3. Block ____ 92 4.Lot _28 5. Type of Facility. 6. Name of Building fi. BUILDING OWNER 7.Name___ Century Realty Inc. 8. Contact Person 9. Tel. # 212-267-7778 Fax # 10. Address City State Zip lll. GENERAL CONTRACTOR 11. Name Tel. # IV. ASBESTOS ABATEMENT CONTRACTOR 12. Name Benjamin Kurzban & Son Control 13. Contact Person Louie lannico 14. Federal Employer ID. # Pll | 45. Tel, # (718) 531-2900 Fax # (718) 209-1808 16. Address 1248 Ralph Avenue City Brooklyn State NY Zip 11236 V. THIRD PARTY AIR MONITOR 17. Name Warren & Panzee ENGIN ERS {ue . 18. Contact Person Mieuacr Now 19. Federal Employer ID. #: Pll 20. Tel. # (212) 922-0077 Fax # (212) 922-0630 22. Sample Analysis Laboratory 23. NYS DOH ELAP # Vi. PROJECT INFORMATION 24. Starting date for this portion of work 6 feelo a Projected completion date 2/20 (Oo 4 a Asbestos work schedule Oo Monday oO Tuesday Oo Wednesday oO Thursday oO Friday O Saturday oO Sunday Shift from: DO amO pm to DO 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 _ 50 Square Feet, and/or _ Linear Feet , NYC-WTC_000111283

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NYC-WTC_000111283Source: NYC Law Department, mirrored locally

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