Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59.17 Junction Boulevard. 8" Floor. Corona. NY 11368-5107 i /elf HAi0Z e a it Dep . or TRU No ONLY FOR OFFIcw. USE ONLY TYPEWRITTEN t~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED —~'~• i'!c. 1.

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.

1. FACILITY n •-~ 2. Address sa ( 2C7 A-1 tA] A ( Borough tip I ID O~ T AKA _ 3 i — ~t -7 1920 A-6W F 3. Bloat 1 4. Lot 5. Type of Facility 6. Name of Building It. BUILDING OWNER

7. Name 50 _0i4 -D&/-}- J& C' • 8. Contact PersonI2A(JL- K E rL % C7 ` 9. Tel.# 112-7 32-L/7 7 6Fax# a) (o l9 —(0433 1I 10. Address ca~~0 _&r o _alt _City N _ __ w State A) Zip O 00 11I. GENERAL CONTRACTOR

11. Name Tel. # IV. ASBESTOS ABATEMENT CONTRACTOR

• 12.NameJ13EIL _ O 13. Contact Penton ' 7 ) C_ ` 14. Federal Employer ID. # P11 115. Tel. # cl 16 - 7,Ft -3 0 Q 0 Fax # 5I ?& 3 .s Q ~ 16. Address ~/ it )C~~_City _State Zip 1(79..? V. THIRD PARTY AIR MONITOR h ,1 r 17. Name Z'`t AT(ZE2 Gr : S fc 18. Contact Person n'`t i- t OLM1 19. Federal Employer ID. # 20. Tel. # a (P - 9aa - O Fax # .2j 21. Address 00 e M % Hr-J S( E City _9+-p K State ~ Zip 00 ) 22. Sample Analysis Laboratory~~ St (T(1t C— i~ t _ ~~'~Es cr~ 23. NYS DOH ELAP # (I VI. PROJECT INFORMATION 24. Starting date for this portion of work -- Projected completion date

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday El Thursday ❑ Friday ❑ Saturda Q. Sunday

Shift from: 0am0pm to Dam❑pm If other. specify ~~ WEIVED Access to *LVect the premises awst be provided during the work schedule indicated in tlrs kern. — SEEP 13 ~/ D 02 ~ U~tIhIR 25. Total amount of asbestos-containing material to be abated during this work

I fI ,-~-- Square Feel and/or Linear Feet ACP 7 28001 •4~i::F.y $r.~ ')S L'w:R;{SEAT

NYC-WTC 000111322