Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

I~nonp, NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ♦`O ' •• Asbestos Control Program Ar 0- 59-17 Junction Boulevard, 8" Floor, Corona, NY 11368-5107 Building Dept or TRU No ONLY D "'"p FOR OFFICIAL USE ONLY TYPEWRITTEN ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED "~ "r~:ig;~ur, (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 .

L FACILITY

2. Address 3.__ ~ P I~t~t'I~ IL (,. J1c Borough Zip 1o o

AKA _ I ~rrO t LA S T 3. Block 4. Lot

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

7. Name _— '` .&t _ PcL T —( Lj_C. • 8. Contact Person K e n,,~• . 9. Tel. # 24~ 31298 3E— Fax# ~( 10. Address _p_ C> ' &0')C 7-2 City ~~~~~~~ State N_ ! Zip _ll __ot

Ill. GENERAL CONTRACTOR

11. Name______...__ —__ ' — Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _ C'iQ W- 1, 'ol ^~ — _13. Contact Person , 14. Federal Employer ID. # . ^~ P11 15. Tel. # _f - 7b -346 0 Fax #

16. Address o ~( ~' — _____City —_ State /V 4- Zip 1i223'_ -

V. THIRD PARTY AIR MONITOR + 17. Name ___~1 ' v ) Q8~ ~ k► (ZE IZ j.IGr S+ __18. Contact Person

19. Federal Employer ID. # ~~~~.5 20. Tel. # aa -C Fax # Ja_

21. Addressgl [ ( E 7 — City W`€I"~ e/= ________State f Zip LOO

22. Sample Analysis Laboratory ~((((1.L 4ir 7 ~(-1S v~ — 23. NYS DOH ELAP # _/ LC

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

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

Shift from: _ Dam ❑ 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 7

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NYC-WTC 000111412