Asbestos Project Amendment form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program ,.Y 59-17 Junction Boulevard. 8" Floor. Corona. NY 11368.5107 •

ITTEN ASBESTOS PROJECT NOTIFICATION S WILL BE "` (ASBESTOS INSPECTION REPORT) CCEPTEO !! ie!!t.

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 OEP not less than one week in advance of the start of abatement activities.

1. FACILITY 11 11 Zip J O O3C 2. Address -- ~?, 1n1t ( 4A S 12x- Borough

AKA 3. Block 4. Lot

5. Type of Facility 6. Name of Building II. BUILDING OWNER

7. Name W l LLIPc►M ST ,A sS CC I R (E -S ' 6. Contact Person 9. Tel. A Fax #

10. Address I -O U h city N &- r'State 1 Zip 0 T "

III. GENERAL CONTRACTOR

11. Name Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name e ✓ 13. Contact Person 7 y_(1'&/,9 C I L ,. ~y 14. Tel. # $l 6 _7I -3"0o Fax# 5(- ?d,' 3'85 16. Address .2olb&EL)S ,4yt City L) State 4J Zip I f 7

V. THIRD PARTY Aljtt MONITOR p ~j `r 17. Name l 4 R.& 4 ZFQ L16 r • KS f C 18. Contact Person n1t L r'~0I" t.

19. Federal Employer ID. #____________ 20. Tel. # af3 - 9aa- 00J Z Fax# ?-Ia_2O30 —

21. Address € A 1 1L S'l Lf E city 9 -64 1 i7=1t_ State _ Zip 00 0 )) 22. Sample Analysis Laboratory S2i (1i G. i- o1 7 1ES{ vc 23. NYS DOH ELAP # (f 'i -d

VI. PROJECT INFORMATION 24_ Starting date for this portion of work 0).... Projected completion date t_

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Friday ❑ Saturday ❑ Sunday

Shift from: ❑ am ❑ pm to ❑ am ❑ pm '

If other. i slimy i ~` RECEIVED Access to Inspect the promises must be provided during the work schedule indicated in firs kern. SEP r1 'DO1 25. Total amount of asbestos-containing material to be abated during this work S' 2 00 Square Feet, and/or Linear Feet \ ILt ACP7r

tCn ~

NYC-WTC 000111338