Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

Aj.C;T70[~,v,jf NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program 59-17 Junction Boulevard, 8tl Floor, Corona, NY 11368-5107 of TRU No Building Dept. ONLY -II , IA. FOR OFFICIAL USE ONLY TYPEWRITTEN ASBESTOS PROJECT NOTIFICATION FORMS WILL BE _""~Nctira►xo~`°~ -• (ASBESTOS INSPECTION REPORT) ACCEPTED ww.: r o a<r (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 J — G— e 5 — Borough ~~ T -- Zip 1`

AKA —__— ---- —_ 3. Block — --__ 4. Lot _-----

5. Type of Facility___------------ 6. Name of Building II. BUILDING OWNER p 7. Name _~ gL~ ~1 8. Contact Person ^ --- N ----

9. Tel. # _--_~------- Fax # _--

10. Address 1pt _ AvU ~~ Lt P_ — City —g ` .1- -- State Zip _

III. GENERAL CONTRACTOR

11. Name_---__ —__— -------------Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _ 'eIL C 1_. 'C.?_l._._._._._._---------- _13. Contact Person

14. Federal Employer ID. # P I I ------_.Y_.[15. Tel. # J _'346 Fax #

16. Address 01~ (~,~ ve_--- — City )% L _--_ State /U Zip LL22

V. THIRD PARTY AIR MONITOR

17. Name ~ kr(2E2 I61 ~2 fC 18. Contact Person Vl~tc EL o (^hr~ .

19. Federal Employer ID. #4 ---------------- II 20. Tel. # a r~=~aa - O Fax #

21. Address g L ~~{ --- City 1L12 ___ State )'~ Zip _LOO ( _

22. Sample Analysis Laboratory__ .(. (((f_ A'1ga ~~`Y'«S u c 23. NYS DOH ELAP # .L/

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

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

Shift from: —«— 0 am 0 pm to _ 0 am 0 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 euREAu Or EHFv"rjueNTal. 3 E~~rOPCEMEryr ASac;tOicr81ROL PrICCP)M rgnp

NYC-WTC 000111440