Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program DI040 59-17 Junction Boulevard, 8 Floor, Corona, NY 11368-5107 Building Dept or TRU No ONLY ~'• FOR OFFICIAL USE ONLY PEWRITTEN TYPE ,~r!~raino~c ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1. ACCEPTED +. (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.

1. FACILITY Q , Borough 1" Zip

AKA 3. Block 4. Lot

5. Type of Facility 6. Name of Building

e~~~ T II. BUILDING Z OWNEERJ s] i 7. Name t CAz.P 8. Contact Person 2 tZ 2~, S-1 C1

9. Tel. 7 Fax # __ #Vt! '+L_ t 10. Address d-~ 1~ILQ _Ciry __N . i__ State Zip _ ô6

III. GENERAL CONTRACTOR

11. Name_ _.._ ____ ___ Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name eIL l_CJ~ ____13. Contact Person _i ac L_ _—__` / ? 14 Federal Employer I PII i15. Tel. # c1 ! - 0 Fax # JLL2Ai✓dos

16. Address oc vt i ~ _ City __ State Zip .iLZ

V. THIRD PARTY AIR MONITOR Ar 17. Name ___ 1Lv '` *4 ZE2 /JG 1 _ P 18. Contact Person AI~~ L ''`"("

19. Federal Employer ID. # PII __ 20. Tel # — -J O0 Fax # is=~ ~~ 2 ' ~j O

21. Address 1 ~ ( City ~' State ~ Zip 00'01 l ic'f /ES 22. Sample Analysis Laboratory___~C ( '! / L /(?gC ct' 23. NYS DOH ELAP # _ / g -y

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

Asbestos work schedule 0 Monday ❑ Tuesday 0 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

Square Feet, and/or Linear Feet 1 'it , :{ P .....Al 3 ijca;7cAT tGu ~

NYC-WTC 000111384