Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ~`•° "'~~~ Asbestos Control Program 59-17 Junction Boulevard, 8'" Floor, Corona, NY 11368-5107 Building Dept. or TRU No ONLY t~ FOR OFFICIAL USE ONLY TYPEWRITTEN ' ONNiNra.aoR°fir ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED • -=_rt e:rder (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 _l4 __ C i1k2~ S ~ Borough N Zip O OO

AKA 3. Block 4. Lot

5. Type of Facility_____-----N— -- 6. Name of Building II. BUILDINCa.4.NER

7. Name --------------------------P I I ._._._._._._._._._._._._._._._._._._._._._._._._._.r 8. Contact Person -- ----- ---

9. Tel. L P11 ax

10. Address --I!--------------------------------------- Ill. GENERAL CONTRACTOR

11. Name Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name -~0' ~ _13. Contact Person

14. Federal Employer ID. # PI I ._._._._._._._._._._._._._._._._._._._._.. 15. Tel. # __~__-----_--000 - 6!6 7P - 3 Fax

16. Address City ~ --- State /U Zip LL22 - V. THIRD PARTY AIRMONITOR

17. Name C 18. Contact Person

19. Federal Employer ID. # P~ 20. Tel. # ( a -OO — Fax #

21. Address g> _L— ~ _/-- City _L --_ State L- 4_ Zip _LOO ( _

22. Sample Analysis Laboratory—!( ((~«- G~ s 7!L c 23. NYS DOH ELAP # _L_~. _____

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

Asbestos work schedule ❑ Monday 0 Tuesday ❑ Wednesday ❑ Thursday 0 Friday 0 Saturday 0 Sunday

Shift from: __-- ❑ am ❑ pm to 0 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

0 D Square Feet, and/or Linear Feet 7 J P )1 8JPEA41 or E!1_IP*'IMEf:Tn 46'o:C'.i7G•:V 3 ehflGCfifEhT CSac r.^ Cr;aRC( PSC~?AAI rrn~

NYC-WTC 000111439