Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

00•'c;,,I,~ NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION 4`•° " ~• Asbestos Control Program D~ rP 4 59-17 Junction Boulevard. 8°i Floor, Corona, NY 11368-5107 Building Dept. or TRU No ONLY 4 tom FOR OFFICIAL USE ONLY TYPEWRITTEN ~ ' ASBESTOS PROJECT NOTIFICATION FORMS WILL BE __ (ASBESTOS INSPECTION REPORT) ACCEPTED (See fee schedule)

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

2. Address ST Borough - Zip

AKA 3. Block 4. Lot

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

7. Name 53 A 1v `l~ . 11 ' 8. Contact Person

9. Tel. # Fax #

10. Address ~ 5 1 31I!. [ City ~ _~ State Zip _15 ) 1

III. GENERAL CONTRACTOR

11. Name— --_~ __ N Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ( — 13. Contact Person ~~----~--` J 14. Federal Employer ID. # P! L . . 15. Tel. # J 16 7, 1"3"0 o Fax # J~ / 3 __

16. Address 3ol~ j /e ---_— City _ State /Q Zip .iLZ__

V. THIRD PARTY AIRMONITOR

17. Name _ v t 4_ ~l ZE~NGt4'~S C_18. Contact Person I' 4 l-

19. Federal Employer ID. # ____ PII 20. Tel. # 2(3 - a - OO 7_ Fax # z~a= ~2 'O 0 21. Address ~~ g C ' City € I ---_ State ~~` _ Zip _(2 ( .

22. Sample Analysis Laboratory~~(E(`(r (F~G h ~ °X'(~S ~ — 23. NYS DOH ELAP # JI g- C VI. PROJECT INFORMATION 24.. Starting date for this portion of work _ _ Projected completion date

Asbestos work schedule 0 Monday 0 Tuesday 0 Wednesday 0 Thursday 0 Fri

Shift from: ❑ 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

y . u ~~ Square Feet, and/or Linear Feet '7 e'J A'I tr D1 qu.: i •a7MY s t1,i F~f t ;c~;WS C:.a1RGl EAT rru~

NYC-WTC 000111392