Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

GTYOE►.rpT NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ~`•~"~ ' F BI Asbestos Control Program Ar 59-17 Junction Boulevard, 8'" Floor. Corona, NY 11368-5107 Building Dept. or TRU No ONLY FOR OFFICIAL USE ONLY TYPEWRITTEN %~~NENru:~~°~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE - (ASBESTOS INSPECTION REPORT) ACCEPTED r w:^v~.iert+.~, (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 LL >k0 A i tn A -( -- Borough N • — Zip ) 0 O

AKA 3. Block __--- 4. Lot

5. Type of Facility, 6. Name of Building

II. BUILDING OWNER

Name _9- S— LO A -- -NS2 0 C Contact Person _ L? -- .— '

Tel. #L 7 ax # --- ---- 10. Address _ 0 _ g ---- City _ L._ State ' _ Zip

III. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name e rE'U 13. Contact Person

14. Federal Employer ID. # l P11 ` 15. Tel. # 6! 6 - 2 - '3S 0 Fax # 5/e7~ -3di_5 16. Address s ) old v ~-- — City _ / / /Z` —_ State .L)4 Zip LL22 _

V. THIRD PARTY AIR MONITOR pp 17. Name y_V Dj *T(ZE2NG I ~ S+~ 1 18. Contact Person

19. Federal Employer ID. # = _rte _=_ 20. Tel. # a (4=gaa = Fax #

21. Address 2 ff1--- city _t €~`~ a7~' --_ State L~ zip

22. Sample Analysis Laboratory— _ .j A`t((«- h*6a ~e-'(~S~ c!o — 23. NYS DOH ELAP #

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

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

Square Feet, and/or _ Linear Feet 7 )1 97PEAU Or Er.'RC•:'~eRTQ 4Eb^C!zrNi~! 3 Ego;c')IEAT PfiOCP:.M rqu y

NYC-WTC 000111434