Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 4 59-17 Junction Boulevard, 8'" Floor, Corona. NY 11368-5107 ONLY TYPEWRITTEN D A ~~ Ar ASBESTOS PROJECT NOTIFICATION Building Dept or TRU No FOR OFFICuLLUSEONLV o FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1 ACCEPTED ".~.!e~J"sc' (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 _! 4— j 4j4 A ( S 1 kzs ( Borough _t'1v'' ( Zip 10 o b

AKA Z~ u~~A"{ S ( 3. Block 4. Lot

5. Type of Facility 6. Name of Building 1I. BUILDING OWNER

7. Name tl`l S lA 1 LD1rJ ci C-. ' • ' 8. Contact Person

9. Tel. # Fax #

10. Address r__ A1€ f S ( __ City ~ State _ Zip 12° t7 III. GENERAL CONTRACTOR

11. Name______.___ Tel. # —

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name e1L lam---_~!-O -- 13. Contact Person

14. Federal Employer ID. #_L P 5. Tel. # J L _ 7L 300 0 Fax # _ J _773dc _

16. Address ~1~~~1 1~ — City J lg l /__ State /v Zip

V. THIRD PARTY AIR MONITOR r)) ~r 17. Name ~ Q- Zr tL /~l(ai~Fr' 5+fc_18. Contact Person P~. 19. Federal Employer ID. # .-.-.- __ 20. Tel. # Q(~=±L -OQ- Fax # a_~~ 'Q6 30

21. Address >;2P g 1 1 City ~`~wJC— State ) _ Zip _LOO / 22. Sample Analysis Laboratory S2( r,F(' - 1, A a AA L S Jc — 23. NYS DOH ELAP # _ t

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

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

Shift from: 0 am ❑ pm to ❑ am 0 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 5-5 Square Feet, and/or Linear Feet

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NYC-WTC 000111414