Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION O ' ~``y. Asbestos Control Program D P 59.17 Junction Boulevard. 81° Floor. Corona. NY 11368-5107 Building Dept. or TRU No A ONLY t~l FOR OFFICIAL USE ONLY TYPEWRITTEN +~,~ ~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE `"0`~ (ASBESTOS INSPECTION REPORT) 1. ACCEPTED ~'~ ercaeae~r, (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 00 2. Address _ S ~— ill y' 1._— ! I E T Borough 2ip 1

AKA 3. Block 4. Lot

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

7. Name _ W t_ S~~ ~~ ( L-t ' 8. Contact Person IA± &F- 'L-

9. Tel. # Fax #

10. Address _%3gS W _ Arfl1► A City --E '{ State N . Zip _— O (~

III. GENERAL CONTRACTOR

Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ~CJ~✓ Q.(._._._._._._.~---- - —__13. Contact Person p C 14. Federal Employer ID. #_[ r II 15. Tel. # J ^~ O~ O Fax # _ . _ Jd~5

16. Address o [~ `~_------ City —_l L State /v Zip

V. THIRD PARTY AIR MONITOR

17. Name ___i R C-18. Contact Person _ t *EL f (° L

19. Federal Employer ID. #[ PI! r_ 20. Tel. # af =1 2a -OD -7 ?— Fax # 3 -O6 O

21. Address —/— City _LL State ` Zip _(o0 ( .

22. Sample Analysis Laboratory__~~ f fF(C- 4*6 t r`1'/-ES~ ~ ~ 23. NYS DOH ELAP # _ L f 41

Vt. PROJECT INFORMATION 24_ Starting date for this portion of work Projected completion date I I r-1 Asbestos work schedule 0 Monday 0 Tuesday ❑ Wednesday ❑ Thursday ❑ 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

t~ Square Feet, and/or Linear Feet 7

~h11R6hc1T ;• '~a rrn ~

NYC-WTC 000111394