Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

„y,cirr Ilfl, NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION r`° "~~ Asbestos Control Program 6111W 59-17 Junction Boulevard, 8"' Floor, Corona, NY 11368-5107 — -- f . "' p /1 Building Dept. or TRU No ONLY FOR OFFICI L USE ONLY TYPEWRITTEN +° 0' ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1 ACCEPTED _—^r5::e+loci - (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 OEP not less than one week in advance of the start of abatement activities .

I. FACILITY w ~/ 2. Address L [e. ~ ( Borough Zip bD7- AKA---------------------_________- 3. Block —N 4. Lot

5. Type of Faci:;ty, 6. Name of Building 11. BUILDING "" `""'"._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._ _ I ---------------------------------------------------------

7.Name „ 8. Contact Person ~ .- II ----r---------- ------ -__.P I I --Y--_ 9. Tel. i Fax # --.—_—. _._._._._._ - t~ P II City W~/'t- State _!v zip 0 ~ _ 10. Address L~ZL!' qq

Ill. GENERAL CONTRACTOR

11. Name_--__ __— _ ----- N Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _ (~~1~ w 2.`-'_,U _---- /---_13. Contact Person _306 14. Federal Employer ID. # y15. Tel # 61 7th a- 0 Fax # 5L 7V 345 16. Address O1 ------ City ----/ L/ —_ State / zip _LL2 3

V. THIRD PARTY AIR MONITOR nA 17. Name ~ k►'tZE~NGr^~ -18. Contact Person

19. Federal Employer ID. # _ 20. Tel. # a(~-±Laa :2P _ Fax # 21. Address g>L ` ✓ r —_ City ~w~C State L-~Y Zip

22. Sample Analysis Laboratory (f(17 L ~ 6 _______23. NYS DOH ELAP ~`~'-I £ S

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

Asbestos work schedule 0 Monday ❑ Tuesday 0 Wednesday 0 Thursday ❑ Fri

Shift from: _ — 0 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

L/ 'f9- Square Feet, and/or _— Linear Feet 7 q BV?EAIJ 9r t P )t EINlR:1,YN~!lral QEb'cC~ATN;t 3 E6r;;kC£1'ttlr e;2c; . $ C' f uu"RAAI 'RCL" Is,''

NYC-WTC 000111432