Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

u1ef, NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION I

D 1A p 4'° "t. Asbestos Control Program 59-17 Junction Boulevard, 8'" Floor. Corona, NY 11368-5107 Building Dept. or TRU No 1 ONLY : TYPEWRITTEN '~i~,,~ ~ ASBESTOS PROJECT NOTIFICATION FOR OFFICIAL USE ONLY

`"ytNrrri~nt FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1 ACCEPTED , r`-° ? . (See tee 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.

1. FACILITY ~. 2. Address _ S~ C H -i M ~. 1 1a_E. ..T Borough M• ( Zip C t o cr j

3. Block 4. Lot

5. Type of Facility__-- 6. Name of Building — II. BUILDING OWNER

7. Name .. ----- .__._PI~~. 8. Contact Person _—~

9. Tel. # P1 1 ax # — 10. Address _ — __r City --- -L.. 0 State 1~+J Zip _L 13 N III. GENERAL CONTRACTOR

11. Name —M—_— Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name (F Q ' .L-------- 'I —--_ ` f 13. Contact Person - ) ? L~

14. Federal Employer ID. # ! ~— ZQ557 L--.SL--1L — 6 15. Tel. # ; — _ 7~~ - 6,60 Fax # _ cam!' _ ~~/ 3✓d~s ~-----_ 16. Address 3Q1Q )S ~— — City J / it/i _ State /J Zip iL29 _

V. THIRD PARTY AIR MONITOR A ~r 17. Name v R +I►'(ZC ~Z NG r ?~ S P' 18. Contact Person ti4 L ''` `'L

19. Federal Employer ID. #L 5 ±L..... 20. Tel. # a /3 ~a - O0~ ~_ Fax # -/3 — 2 'G6 3 0 21. Address [— '` S' r r —~ City 1L c1= — State l~ Zip -L0O ( .

22. Sample Analysis Laboratory— Sr ! (/;c~G h c 7-A r°7fC-S cr c 23. NYS DOH ELAP # .i ~-~

VI. PROJECT INFORMATION 24. Starting date for this portion of work _ __ Projected completion date r 1 I- I Asbestos work schedule ❑ 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

110 Square Feet, and/or Linear Feet 7 CJ':A'r ~• .Jt p~•.••i!1: '•`C: YS 4L 4,iJtCfi.7.zAT 4c'C'•ii G"_7ilRC•C rFC~PAM rrIl

NYC-WTC 000111396