Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

~,r 0Q NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION 0 ~`.° Asbestos Control Program 59-17 Junction Boulevard, 6'" Floor, Corona, NY 11368-5107 - — IA — Building Dept. or TRU No ONLY D ~ IT ~ FOR OFFICIAL USE ONLY TYPEWRITTEN es,°NM~hr~~ n~~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1 ACCEPTED -"-".:"! 5 ='"!"1C. (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.

FACILITY

2. Address ;~ o -t J j,~a ~ — Borough ~-- Zip _ t1??P7

3. Block -- 4. Lot

5. Type of Facility___- - ------- 6. Name of Building

II. BUILDING OWNER t

7. Name _-------~—__— -- 8. Contact Person S= -

9. Tel. #~a-1~) ?-33 ? l — Fax # ---- ---- 10. Address o~~D~ a 1'~0'~fl p► --- City --I ' __-- State ~ Zip

Ill. GENERAL CONTRACTOR

11. Name----------------------------------- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name (~ ~`'. -------- _13. Contact Person

14. Federal Employer ID. # _L PII `15. Tel. # 1L - 7J -3400 Fax

16. Address 0ID 8C~ — City J /!fir _ State /L Zip ILZ2_ _

V. THIRD PARTY AIR MONITOR nA 17. Name y J ); ~ ~'►~ Zt &61 1-S+P18. Contact Person

19. Federal Employer I0. # ` P11 . 20. Tel. # 2 fa=~aa - 00 — Fax # 21. Address L__ —/-- City ---_ State Y_ Zip _ 00 22. Sample Analysis Laboratory-- ~C (H`(~( ~L G~ a r °~S U — 23. NYS DOH ELAP

VI. PROJECT INFORMATION

24..Starting date for this portion of work _------_ Projected completion date 1 1 P9 Asbestos work schedule ❑ Monday ❑ 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

,- Lr5—Q Square Feet, and/or _ -- Linear Feet 7 ]1 BJP.(AU IR.^,rll~. Y:S;zCi:(If.•V; rht~pr~ITAI ;•')sCC:, RC.( `^^~RAAI ton 9

NYC-WTC 000111430