Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

Ay,L, TY 0GA4T NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION 4~0 ' A, Asbestos Control Program A r~ ' 59-17 Junction Boulevard, 8" Floor, Corona, NY 11368-5107 ONLY D ASBESTOS PROJECT NOTIFICATION Building Dept. or TRU No FOR OFFICIAL USE ONLY TYPEWRITTEN '+oNMCNruiao~`cd` FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED (See fee schedule)

When submitting this form at the N l: signatures are required. Submittal F12-/ I. FACILITY form must be submitted to the NYC

2. Address _L Lf5k0A6 ? / ( ?(øaLway _ a~

Ib kl!13 r' r AKA ----------------. ~V 1 ~i,f 5. Type of Facility______-- II. BUILDING OWNER /"'`ter

7. Name CV~ 9. Tel. #c-21a~3 /

10. Address _ r— 1 •

III. GENERAL CONTRACTOR

11. Name --- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR pp ~. 12. Name ( /~V _ _ _ _ _ _----`N--_13. Contact Person

14. Federal Employer ID. # -- 15. Tel. # J _ Fax # 151 ✓dt~s

16. Address od (~ ~_--~-- City State N Zip _L22

V. THIRD PARTY AIR MONITOR

17. Name G (~ Z~rz jJG i ~S e 18. Contact Person ~ 1- (0L

19. Federal Employer ID. # J. P11 L_ 20. Tel. # a (~= a _Q _ Fax # a~~~=06 30 21. Address 512 g L— — E --_ City I1 State (~ Zip __ 22. Sample Analysis Laboratory— S.J. (LEC - h o Lf!1E3 v c — 23. NYS DOH ELAP # _.L/_ L. VI. PROJECT INFORMATION 24.. Starting date for this portion of work -

Asbestos work schedule 0 Mond:

Shift from: __ ❑ am ❑ pm t,

If other, specify

Access to inspect the premises must be

25. Total amount of asbestos-containing n

a3 Square Feet, and/or _ 7 ti'J?rAU OF EN:R y,!/EMTAL 3 EPiFLErt' T 45'.:C~ARf.ros PAO~a:.dl

NYC-WTC 000111433