Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION .►'•°~' ~ Asbestos Control Program D0 r~ 4 59-17 Junction Boulevard, 80 Floor, Corona. NY 11368-5107 Building Dept. or TRU No ONLY FOR OFFICIAL USE ONLY TYPEWRITTEN c~~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED . !' "-r <.*-•`~'•~. 1 (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 (° tr['~~► ~1 Q ' (L T Borough N • l — Zip , 0 0 b 7

AKA 3. Block 4. Lot

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

PII 7. Name . _._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._ 8. Contact Person P~ ~ L

9. Tel. P II Fax # _._. L17 -~ 10. Address PII_._._._._._._._._._._._._._._._._._._._._i_ Ciry ~— State , .._j Zip _P—_!3 ,

III. GENERAL CONTRACTOR

11. Name_— --- ~ —_-- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name 1..~ 1~O _ —N— _13. Contact Person 3 L~ ! C 2 14. Federal Employer ID. # -. - -. .- 15. Tel. # ct ^'3060 Fax # c~~ J~~S

16. Address 01~ 1~ ~'_-- — City _ - State Zip 1L2 9'-?

V. THIRD PARTY AIR MONITOR A ! 11 A+ 17. Name ___ ZED NG P18. Contact Person ii4 t-

19. Federal Employer ID. # L PII 20. Tel. # a_f ~aa- OOH — Fax # . O ,'3O

21. Address ~~ g 1 1 4X "' ~— ~~={ City f ~7=__ - State Zip LOO ( .

22. Sample Analysis Laboratory ~1 (fl` ( ( 23. NYS DOH ELAP #

VI. PROJECT INFORMATION 24 Starting date for this portion of work Projected completion date -- N— _ —

Asbestos work schedule ❑ Monday 0 Tuesday ❑ Wednesday 0 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

4 0 _0 Square Feet, and/or — Linear Feet 7 9P 11 iA Irh•Eir'~`~HcMAL

IPn

NYC-WTC 000111398