Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard, 8'" Floor, Corona, NY 11368-5107 — -- Al Building Dept. or TRU No ONLY FOR OFFICIAL USE ONLY TYPEWRITTEN ' O"'Mranuii~Qn°c~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1 ACCEPTED =mow ^_Yi ica?•r, (See fee schedule)

When submitting this form at the NYC Oepartment of Buildings, the original form and three (3) copies with original signatures are required. Submittal at the NYCOEP 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 _5

AKA — ..... J_"_Lld.i_ L 1 _ 7 5. Type of Facility, I1. BUILDING OWNER

7. Name

9. Tel. # A ~j

Fax # Lu ( c i 10. Address

Ill. GENERAL CONTRACTOR

11. Name--------------------

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name Lh f G' ------- - _13. Contact Person _ ~ L / _—

14. Federal Employer ID. # P11 15. Tel. # _iL_! ^ ~~_3460 — Fax c

16. Address 01~ v_ 1_ ~_--__--- City _L /t (..6 /2/ State /v Zip 1122 _

V. THIRD PARTY AIR MONITOR rr 17. Name j 12=€]TR >t77,(ZjFP— ~ S —_18. Contact Person

19. Federal Employer I0. # L P11 r 20. Tel. # a ra=9a - OO1_ Fax #

21. Address g>'4s_L__ _ ~✓ —JJ-- City 1 Q . State Zip~_LOO (

22. Sample Analysis Laboratory_ SC_(£1`~(l~«- 4_ C 'I` u — 23. NYS DOH ELAP # c1

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

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

Shift from: __-- 0 am 0 pm to -- 0 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

— Square Feet, and/or _— Linear Feet 7 BUP,EAU OF 7i 9E1A.LYaTlf.:4EJViRafIMFMTAL S Er;F~PCEAtEhT a ros ACCCr,;~tRCt PFfiu'PAA1 mn7

NYC-WTC 000111428