Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

;i cz NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59.17 Junction Boulevard. 8" Floor. Colons. NY 11368-5107 E

,%wP ASBESTOS PROJECT NOTIFICATION Building Dept. or TRU No FOR OFFICIAL USE ONLY

~r _ : (ASBESTOS INSPECTION REPORT) 1. ACCPTE ' 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 r = t om _ • 2. Address lI b GF4 $ S ( (t.F- 1 Borough Zip I OoO

AKA

5. Type of Facility 6. Name of Building 3. Block i 4. Lot _ -'-f It. BUILDING OWNER

7. Name ST • - • • S. Contact Person -r 9. Tel. # Fax# 10. Address t r --? - 3< A- J Cit State IZip I L3Slf

III. GENERAL CONTRACTOR

11. Name Tel. # IV. ASBESTOS ABATEMENT CONTRACTOR

_ ~ . ____________________________13. Contact Person / ) (~ ` 14. Federal Employer ID. # P I .. 1' - 7 -/ -300 p 5. Tel. # c~ Fax # SI - 7d,'-3c'85 16. Address 30/ b &)I?/OS /TYt City _Li 1 State Zip V. THIRD PARTY Al MONITOR ~1 r 17. Name P.$~t ZE!L Iii rN4~~S, PC 18. Contact Person %1t E- f.. oI^p 1. 19. Federal Employer ID. II 20. Tel.# afP- 9aa-OOjZ Fax# .2J9- 22_o _30 21. Address ~t2 g -L.4 1 S' fEG City _ State _ Zip 00 t s 22. Sample Analysis Laboratory Setet1 — L _ _ r,4 w1ESP= ctc 23. NYS DOH ELAP # (I C

VI. PROJECT INFORMATION 24.Starting date for this portion of work Projected completion date I O 0 > _f Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Friday ❑ Saturday .0 Sunday

Shift from: ❑ am 0 pm to fl am ❑ pm

N other. 4 F spespecify j~ RECEIVED Access to inspect the pantises must be provided during the work schedule indicated in Otis Item. SEP 13 ?00'1 25. Total amount of asbestos-oontainirtg material to be abated during this work '~ Rt Aral YN %' I Square Feet. and/or Linear Feet o~ ra ~' ~ rte. . •, wcer 211001 4 135 I[CJ.JI ICa ~ X..

NYC-WTC 000111326