Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION `00 `+• Asbestos Control Program 59-17 Junction Boulevard, 81° Floor, Corona, NY 11368-5107 Building DepETRU or ONLY FOR OFFICIA TYPEWRITTEN kr~ wrK n~~d ASBESTOS PROJECT NOTIFICATION FORMS WILL BE -- (ASBESTOS INSPECTION REPORT) ACCEPTED 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 I C Ff4 v i2.21 S 1 - orough fSJ 'f Zip 0 00

AKA — 3. Block 4. Lot

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

7. Name PII Y_ . _ . - ray r- 8. Contact Person

9. Tel. _. _. Fax # =._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. ~` 10. Address P11 City ---~--- State Lv Zip _

III. GENERAL CONTRACTOR

11. Name_— --_ Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ._.J 'el` Gyi , o± ------- _—_13. Contact Person

14. Federal Employer I . D# PII 5. Te1. # -- L j ' 2j -300 0 Fax # c~~ 7~ —__--~ -3dt~5 16. Address Sol- I8v, .A~_-- City ~J 7'V~/~ _ State /V zip iL2~?

V. THIRD PARTY Alit MONITOR ,~ r 17. Name P k► (Z~ Cituft Pc 18. Contact Person 1t~ l- 40—( •

19. Federal Employer ID. # ~.--.-.-.-.- I 20. Tel. # ' ( - 9aa - OOH — Fax #X13= -06 30 21. Address L— ~=f City _7 €k— ~ State ~ _ Zip _(o0 ( •

22. Sample Analysis Laboratory t IFt'L h a 23. NYS DOH ELAP # _

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

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

Shift from: _ ❑ am ❑ pm to 0 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

i!-9 Square Feet, and/or Linear Feet 7 Dt 1. cs:''i i..' i& Pn,,,a;Rl IF•~

NYC-WTC 000111406