Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

G„ er, NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION 4 Asbestos Control Program 59-17 Junction Boulevard. B'" Floor. Corona, NY 11368-5107 Building Dept, or TRU No ONLY D~~ FOR OFFICIAL USE ONLY TYPEWRITTEN h~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE -- (ASBESTOS INSPECTION REPORT) ACCEPTED """_+~ *!'t~.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 OQ ~f Lt~C ST 1ee~.~~ .Y Borough N Zip

AKA 3. Block 4. Lot

5. Type of Facility 6. Name of Building 11. BUILDING OWNER

7. Name _— — L 8. Contact Person

9. Tel. # Fax #

10. Address ~g S I H Or ye)- UL City __J. ( State • Zip _ 0 0

III. GENERAL CONTRACTOR

11. Name_-- N-- _ —_

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name Dell_ Y-) I'Cd _13. Contact Person ~ _____ —,----` -- e 14. Federal Employer ID. # "___j15 15. Tel # cJ 7~r ^3~~ Fax #

16. Address QLv~C~ <' -- —City J _/ _State /L Zip 1L22 3

V. THIRD PARTY AIR MONITOR

17. Name 1&L. LcL i,. c 18. Contact Person t~ L f -

19. Federal Employer ID. # 20. Tel. # ai~-& 2__OOj-3_ Fax # 2J3-~ -O6 -j 0

21. Address TJi 24i City _N' ~ State _Zip LOO

22. Sample Analysis Laboratory SC( (1(F(- ►^ s4 t i 6WIFE'5 a ll — 23. NYS DOH ELAP # _ / r' 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 ❑ 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

a,':1- 4.L5 Square Feet. and/or Linear Feet 7 )1

IFI

NYC-WTC 000111410