Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ~`.°' +. Asbestos Control Program 59-17 Junction Boulevard, 8 Floor, Corona, NY 11368-5107 Building Dept. or TRU No ONLY t>r FOR OFFICIAL USE ONLY TYPEWRITTEN + ~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE __ (ASBESTOS INSPECTION REPORT) ACCEPTED • !5 !?^`•'.~!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 ~/ 2. Address ' ~ S ST Borough N T Zip ' fl 0 O

AKA 3. Block 4. Lot

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

7. Name J5 C &Lt&1.R$ ~T 8. Contact Person

9. Tel. # _-- -- Fax # _— — p ' .1 10. Address 1rt r' —"C1.)~~ u— City _ S ' .1. State Zip ___

Ill. GENERAL CONTRACTOR

11. Name_ -----,—_____ ----- —~ Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR /'- 12. Name e~ ------- ___13. Contact Person

14. Federal Employer ID. # _; PH 15. Tel. # c1 - '300 0 Fax #

16. Address o1 — City ) /!7v /__ (__ State N Zip

V. THIRD PARTY Al MONITOR

17. Name _j'12 v &_ *74 tZ 6 i TES P 18. Contact Person V41tC + 6L 40 (" per•( 19. Federal Employer ID. # ' P 11 I 20. Tel. #

21. Address [_ ~ ✓~~ —— City -~~''~ State t_ Zip £ 00

22. Sample Analysis Laboratory 1 CIfl`~((F(G- G~ c °~'f£S a c 23. NYS DOH ELAP # ,j ~

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

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday 0 Thursday ❑ Friday ❑ Saturday ❑ Sunday

Shift from: _ ❑ am 0 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

Square Feet, and/or — Linear Feet 'T C1cA'I or f D1 4E,' :i+:7M.•V 3tR9']AFt.T,I t;e::<ti5 Ctr,t;;y~FhT :1RC•L tFwR 61 tt,i 7

NYC-WTC 000111402