Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

-- NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program P 59-17 Junction Boulevard, 8th Floor. Corona, NY 11368-5107 Building Dept. or TRU No ONLY D0 FOR OFFICIAL USE ONLY TYPEWRITTEN % O~tvruiaa"° c° ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED w 1. (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 _ L — S T( Z I Borough _t4... SI — Zip -1.00 O -

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

5. Type of Facility___------ ~_ N— 6. Name of Building II. BUILDING OWNER

7. Name Cf4_Pt~Y1~ QrS usE f ! ~I-Z, LL-C 8. Contact Person / I__ NIC.~

9. Tel. # ~'~ _ Dl Fax #

10. Address C E City — _~—_ State/ v`_[_ Zip

III. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name .. _13. Contact Person

14. Federal Employer ID. # _Y=_~ ~, = i1 15. Tel. # 6 _—_ 16- 7 ~ ^ 0p — Fax _ 16. Address 300 ~_v_g' 1_ ~_--__— City J ~/ _--_ State /v Zip _t'LZ2L

V. THIRD PARTY AIR MONITOR eA 17. Name _\r 2 kr(ZE2 f6 r 1 ~S+fS_18. Contact Person •-

19. Federal Employer ID. # 20. Tel. # _L~=1 Fax #

21. Address g>( ✓ _—_ City ' —_ State L-~ Zip 0O( _

22. Sample Analysis Laboratory— CC(-i~c((~~L A6- a gA ~~rtI s: tr , — 23. NYS DOH ELAP #

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

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

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 eJREAu or Et.1R )1 V1,.L`,:tlffy i Etif:.1MEllTA1 CFh;EM o(2 to tpry

NYC-WTC 000111441