Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ` •• DA 4r+• Q Asbestos Control Program 59-17 Junction Boulevard, 8' Floor, Corona, NY 11368-5107 __ __• 1 Building Dept. or TRU No ONLY FOR OFFICIAL USE ONLY TYPEWRITTEN ~~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE ` (ASBESTOS INSPECTION REPORT) ACCEPTED "" r°"1 . (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 LZ`L- & -0 Ahw&1 Borough Zip 1) o

AKA 3. Block 4. Lot

5. Type of Facility_—__________________________ 6. Name of Building II. BUILDING OWNER

7. Name CE tJ 1 Ld jg T 1NG 8. Contact Person

9. Tel. Z=l ' Fax #

10. Address_! L City-- _ — State jZip_

III. GENERAL CONTRACTOR

11. Name Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ~' ~~ ---- ---__13. Contact Person / 14. Federal Employer ID. # l .PI —X—YLI _._._._._._. 15. Tel. # J - 7t ~_ P0 Fax # ------- 16. Address or ~~~✓L' — City _ State A) Zip 1L2~'

V. THIRD PARTY AI~ MONITOR ( 17. Name ~" V ^ (Z -----}.~18. C Contact Person 1~1tC } _---__—_-(~

19. Federal Employer ID. # _ _._~.-.- _._.~_._._._~_ 20. Tel. # 2(3 as - OQ~ ~-- Fax # 21. Address.22 _L— L City L e1 State t Zip L00 ( . J 22. Sample Analysis Laboratory. . ~= (fry P~«- f~ f °x/~$ J — 23. NYS DOH ELAP # lE- ~-1

VI. PROJECT INFORMATION 24.. Starting date for this portion of work Projected completion date r- I r" Asbestos work schedule 0 Monday ❑ Tuesday ❑ Wednesday ❑ Thursday 0 Fri

Shift from: 0 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

a] (QR Square Feet, and/or__ Linear Feet '7 t 31 8 ^eRv p ; .. p,...,Et.^mil <Si•rr'~. C ~'tXGI Y:..vA~ll

NYC-WTC 000111422