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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_000111318–000111327

Folder label: “Zone I Copies

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NYC 9/11 Public Portal Document

~V 1 NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION 1 `` , uiror~y r Asbestos Control Program 59-17 Junction Boulevard, 8" Floor, Corona, NY 11368-5107 /5131(4 Building Dep%oror TRU No FOR OFFICIAL USE ONLY EN \ iiun~c ASBESTOS PROJECT NOTIFICATION L— ILL BE RMSRWTT "u (ASBESTOS INSPECTION REPORT) 1, ACCEPTED +4 tu rer . . (See fee

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 M___ zip _X00 3S __ 2. Address _F3 "A fSS v. u_S'Tt2CEl Borough _

3. Block — _LS ___ 4. Lot __?____

5. Type of Facility_.. MM RCto.~—__—Y ___—_ 6. Name of Building

1I. BUILDING OWNER

7. Name _ u LL MAN 12EA. I —_____ 8. Contact Person t c ra a t2D M At2~ JS

9. Tel. # _t2t2) 3A3=1i L__. . Fax # _ _____

10. Address City NEvs YceK State _J4' _ Zip _1Q&-.___

III. GENERAL CONTRACTOR

11. Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name (BEN-iAMit,! ict1P-'z8 ~ Sc:n~ ~`-cwTVc, lµc _ - 13.ContactPerson_LaQ-~E IAuutCc ------------------------------- P11 14. Federal Employer ID. # .-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-r— = 290b__-- Fax # cYtpsl_o~~If3c~$ —___ ! _ — 15. Tel. # CZ18) 531

16. Address _ 124eRALa►1 AQE4QE ------ City _pQCflKL-4 N —____ State N!__ Zip 110.3 —_

V. THIRD PARTY AIR MONITOR

17. Name LUAePx'N~ PA NzC-Q- 1 a~1 t`t EE" _~ — _18. Contact Person _titCHAEL NIQ!,At —

P11 19. Federal Employer ID. # rt.-.-.-.-...-.-.-...-.-.-.-.-.-.....i-- ' 20. Tel. # 12125 922-c~TY __ Fax # (2 12 ) 922 -oGo—- _ — --- 21. Address _??f$ EAST 45TH S;-.P ET _— City _NEw %oR1c State _N4__ Zip _ 100 1 C

22. Sample Analysis Laboratory 23. NYS DOH ELAP #

VI. PROJECT INFORMATION 24.. Starting date for this portion of work _ 1 (a (0 ' Projected completion date

Asbestos work schedule ® Monday ® Tuesday ® Wednesday ® Thursday 12 Friday ® Satu . .Sunday eca Shift from: __aco 10 am ❑ pm to ❑ 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

_.24Q.._. Square Feet, and/or _._2__ Linear Feet ACP 7 2/2001

NYC-WTC 000111318

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NYC-WTC_000111318Source: NYC Law Department, mirrored locally

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