Asbestos Project Notification Form, DEP Box 39

NYC 9/11 Public Portal Document

I Liçc° .. NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard, 8' Floor. Corona, NY 11368-5107 7 9ZE0_? 'WP Building Dept. or TRU No FOR ocrioAL USE ONLY

ASBESTOS PROJECT NOTIFICATION EME ~.X ACCEPTED NfY Mom

:,••` P•: ~••' (ASBESTOS INSPECTION REPORT) 1 (S fee schedule)

original form and three (3) copies with original When submitting this form at the NYC Department of Buildings. the 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

2. Address ~~wJ~.~Y Borough _t" ' 1 Zip

3. Block 4. Lot AKA

5. Type of Facility 6. Name of Building

II. BUILDING OWNER

7. Name_ ~D i S C.z ' '8. Contact Person / 9. Tet. # ~ ~ 6. ' dD Fax # City N State Zip 10. Address ~ w 1~E t S ' t 2--E-T

III. GENERAL CONTRACTOR

11. Name Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR p 12. Name _ ~ €'!` — f 13. Contact Person ~ P-

14. Federal Employer 10. # P1I 15. Tel. # c7 IG - 7 ~d f^~J000 Fax # Ji —? 3 S / ' 16. Address 3QI Q it )C~j t J tv e City State _zip I!? V. THIRD PARTY AIR MONITOR ~j A ~r 17. Name t,&) ZED 6 t k f 18. Contact Person

19. Federal Employer ID. # 20. Tel. # a (3 - 00~ _ Fax # -24a - 9g2a -46 3 0 fr 21. Address .2Pg k I !~J EE ~( City t + -p T State Zip 00 / 22. Sample Analysis Laboratory S2( '( (c(t_ 4 A6& tortes, `r` 23. NYS DOH ELAP # _If 5' O

VI. PROJECT INFORMATION , 24 Starting date for this portion of work(9 Projected completion date )

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday 0 Thursday 0 Friday ❑ Saturda ❑ Sunday

Shift from: ❑ am ❑ pm to ❑ am ❑ pm

If other. specify r LECEIVED Access to inspect the premises must be provided during the work schedule indicated in this kern. Ji SEP 16U 9OJ2 25. Total amount of asbestos-containing material to be abated during this work

4 r Square Feet, and/or Linear Feet s' j Q 8 • ACP 7 otP 2rtoot - .-

xil l

NYC-WTC 000111328