Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

cirrou~ NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ,.yO"~ Asbestos Control Program 59-17 Junction Boulevard, 8'" Floor, Corona, NY 11368-5107 — --- Building Dept. or TRU No fA FOR OFFICIAL USEONLr ONLY '~" TYPEWRITTEN F '"O~MrHraia°nc~,dr s~;~~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1 ACCEPTED — avi:i ~ (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 O ~_— ^—~ _~ Borough — t4' ^( — Zip _ 1 0 0 0 -7 -

AKA 3. Block 4. Lot

5. Type of Facility_— --__— ---- 6. Name of Building

II. BUILDING OWNER (~ 7. Name _ 8. Contact Person

9. Tel. #L9 E-_—l( Fax # -------- 10. Address ---__ City --N '_ ---_— State w ip_L 000

III. GENERAL CONTRACTOR

11. Name Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name JL~fe G > ICO --------C--- _13. Contact Person

_.-.-~, _ _. 14. Federal Employer 10. # =.-.-___.P11 15. Tel. # J — ---3060 — Fax # J~ --__—__-----___ c s

16. Address 0 , (> i/------City State /U Zip _LZ

V. THIRD PARTY AIR MONITOR

17. Name _— V. \J krt Zr t2 NG I S+f _18. Contact Person 19. Federal Employer I0. #P11 P 11 j 20. Tel. #

21. Address g L__ ~{ City `~"~ ~ ---_ State _Zip _L~~ / 22. Sample Analysis Laboratory— Sc' =(£ i7 -( a rd r- v'c _23. NYS DOH ELAP

VI. PROJECT INFORMATION 24..Starting date for this portion of work Projected completion date r —1 r-, Asbestos work schedule ❑ Monday 0 Tuesday ❑ Wednesday 0 Thursday 0 Fri,

Shift from: ___— ❑ am ❑ 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 5 Square Feet, and/or__ Linear Feet 7 8J2rAU of K'•:fCta?t?+f 3 fyr:pcFrLfhT Pfi1CRAAf toil

NYC-WTC 000111427