Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION S. A Asbestos Control Program ow 59-17 Junction Boulevard, 8tl1Floor, Corona, NY 11368-5107 ONLY : U~P,. Building Dept. or TRU No FOR OFFICUL USE ONLY TYPEWRITTEN '+ ~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1. ACCEPTED td (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 t M C ( 1 AS S ( Borough N f Zip cc> o'

AKA 3. Block 4. Lot

5. Type of Facility, 6. Name of Building

7. Name ` P 8. Contact Person

9. Tel. .-. PII } Fax # - -~-~-~-~-~-~- -~-~-~- -~-~-~-~-~-~-~-~-~-~-~-~-~-~-~-~-~-~-~-~-~-~-~-~-~-~- -~-~-~- • 10. Address P11 - City ___~ ....L_____State _tj Zip _O ~ O_

Ill. GENERAL CONTRACTOR

11. Name Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name j ele ' -- __ _13. Contact Person ~ L~_ / --C 14. Federal Employer ID. # P1 15. Tel. # c1 - 7~( -340 0 Fax # ~~ ~~ d~s

16. Address 01(D jdZv' 1?i!~ City ) /! I /_ _ State /v Zip IL?

V. THIRD PARTY Alj MONITOR ,, r 17. Name Vt &Z P ^~ ~ !t►~(2 2 fGr )? S PC 18. Contact Person _ 61t l—'y (^ -_

19. Federal Employer ID. # P 11 ] 20. TeI. # a (a_1°Ua - 0O_ _'_ Fax # 3 _ 72 ' O. .3O - -.-.-.-.-.... .-.-...-.-.-...-. .., 21. Address ~~ g1 j _ City __ State (-( Zip 00 ( .

22. Sample Analysis Laboratory—_I f f /~(C- ~ *6 E r ~K'1,-S cf c 23. NYS DOH ELAP # ('

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

Asbestos work schedule 0 Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Fri,

Shift from: 0 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 -1 r 10 O Square Feet, and/or Linear Feet 7 •i t P Dl e'JprR'.I qt: L.IF..Yf~"iP^':a'Jtrkl S E~fj:CfiiF1T

NYC-WTC 000111408