Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION r'O~" '`~• Asbestos Control Program q. 59-17 Junction Boulevard, 8n' Floor, Corona, NY 11368-5107 — DA Building Oept. or TRU No ONLY FOR OFFICIAL USE ONLY TYPEWRITTEN ~, NfNruon~~~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE -- (ASBESTOS INSPECTION REPORT) 1 ACCEPTED (See fee schedule)

When submitting this form at the NYC Department of Buildings, the original form and three (3) copies with original 'I 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.

1. FACILITY

2. Address _ tt ~—C T'T~ Ti 2 I1 .. Borough t\J L— Zip _ C O O UL_ AKA --__----------- -- — 3. Block -- 4. Lot

Type of Facility 6. Name of Building II. BUILDING OWNER P11 7. Name J = _ _~.,~, 8. Contact Person ---

9. Tel. P11 rax # ---- ---- 10. Address J PII r City --- N_ state _I III. GENERAL CONTRACTOR

11. Name_----_ -------- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _ L ? _ç- i. . ._._._._._._._._. __ --- _13. Contact Person p 14. Federal Employer ID. # ` r II ._.'S. Tel. # 6` / 6 - 2 ^340 o Fax # 5L _2_~ dt7 S_

16. Address o1 1e_----- _ ) L6f..4 State N Zip LL21~'

V. THIRD PARTY MONITOR { AIR~ 17. Name —v 2 _ A1 + PC 18. Contact Person

19. Federal Employer ID. ._•_._~___,_PII_____r _____—___ 20. Tel. # Fax

21. Address 2Q g L "' ~~~~--//-- City >~~w__ State L- Zip

22. Sample Analysis Laboratory C (£>~f /;cr!L G~ 6 ?ZA ~?-'1~5 cr c 23. NYS DOH ELAP # ~ ~ V • ___

VI. PROJECT INFORMATION 24.. Starting date for this portion of work Projected completion date r" Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ 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

-17 0 — Square Feet, and/or Linear Feet

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NYC-WTC 000111437