Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document }

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION `° gym +•4 Asbestos Control Program aV 59-17 Junction Boulevard. 8'" Floor. Corona. NY 11368-5107 ONLY D'~' A Building Dept. or TRU No FOROFFICUILUSEONIr TYPEWRITTEN 4rawonc ? ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1 ACCEPTED '"' "~` 1~'r!1C. (See tee 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 Q D 2. Address _— —~—-& f- OAbWA•'( ( Borough —Zip OOO

AKA 3. Block 4. Lot

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

7. Name ~~ 8. Contact Person G 9. Tel. i~L') a a'a~ 0 1 Fax #

10. Address _ 2'OL U CS:_— S t N City ---Q State _}_~j Zip _L1) , '3 III. GENERAL CONTRACTOR

11. Name _---- _—_ _---~ Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name fao 1 zO —13. Contact Person ------C 14. Federal Employer ID. # P11 15. Tel. # L~ - 7b_ 3000 — Fax # Jf' ;W- 3 0 55

16. Address jUt ii~ — City ______ State /V Zip LLZ~'

V. THIRD PARTY AI MONITOR )) p `r 17. Name v ~ ._.0~ 6i S 18. Contact Person t4~~1f1-

19. Federal Employer ID. ._~ P I L. LM d- 20. Tel. # a ~3=~aa 04 Fax # G- _

21. Address ~~ g>~ r S (~fi< 7 City _ State Zip _ 00 ( . / 22. Sample Analysis Laboratory S .i t'f (11L F o f 'I£S Af c — 23. NYS DOH ELAP # ~~~(7

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

Asbestos work schedule 0 Monday 0 Tuesday 0 Wednesday 0 Thursday 0 Friday 0 Saturday 0 Sunday

Shift from: _ ❑ am 0 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

4a Square Feet, and/or Linear Feet 'T dtP Dl C'?SAY 1: Eq:9F^^?ra1lTAL .act*:~5 Cn;+lHGL~T P6Co"RAAI

NYC-WTC 000111424