Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION

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t1~ D11t1 Asbestos Control Program 59-17 Junction Boulevard, 8°' Floor, Corona, NY 11368-5107 Building Oept. or TRU No 1 ONLY t>~ FOR OFFICIAL USE ONLY TYPEWRITTEN %~~Nru r,~~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1. ACCEPTED (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 DEP not less than one week in advance of the start of abatement activities .

I. FACILITY ~, 2. Address _ J ff r rim ,t1 g T LT Borough L. Zip

AKA 3. Block _ 4. Lot

5. Type of Facility. 6. Name of Building II. BUILDING OWNER _._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._.

8. Contact Person v' SC, SS~ & 9. Tel. # PII Fax# ---

10. Address< P11 r City _i---...... State Zip_P?9

III. GENERAL CONTRACTOR

11. Na Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _--( eft --_._._._._._ -- _—_13. Contact Person ___` 14. Federal Employer 10. # P11 (/ 15. Tel. # J ` 7~l - c3,06 _-- Fax # J __--__-- LL 2. _--_— Jd~S --_____

16. Address _30hDQl~ v~------ City / / / —_ State /v Zip 1L22 3

V. THIRD PARTY AIR MONITOR

17. Name , ~- - fc 1 18. Contact Person

19. Federal Employer ID. #i A i ,,~_ 20. Tel. # Q1 2P1_ Fax #

21. Address g > ~ > --- City "~w ---_ State _Zip 122. L- _ 1 22. Sample Analysis Laboratory— S'C(f~ f*!(f - X° '~£5 ~' c — 23. NYS OOH ELAP # _L Ef v ___

VI. PROJECT INFORMATION

24. Starting date for this portion of work Projected completion date P1 r, Asbestos work schedule 0 Monday 0 Tuesday 0 Wednesday 0 Thursday 0 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

4.0&o — Square Feet, and/or _—_ Linear Feet

31 eaRrAu tr EFn1erAMJnru. 46't,:C!.aY.4f 3 EISJRCEF 43aE3tOS ff,ArRQI PROGRAM rRl1

NYC-WTC 000111438