Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

, y Sir orragr NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ~'•° '~~• Asbestos Control Program tart 59-17 Junction Boulevard, 8'" Floor. Corona, NY 11368-5107 D o Building Dept. or TRU No ONLY FOR OFFICIAL USE ONLY TYPEWRITTEN '+OwMfNruwro ~c°? 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 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 ~7 2. Address L ~P -- C M~?2EAS S (~ Borough — Zip ~Q~ ~____

AKA 3. Block 4. Lot

5. Type of Facility_—__N __— — -- 6. Name of Building II. BUILDING OWNER . 7. Name 8. Contact Person — PI1 9. Tel. #M W...~..,e~ ~- Fax# —~~- 10. Address PII City----- ~--- State L~I Zip

Ill. GENERAL CONTRACTOR

11. Name_ --`_ Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name J _2 - 'CO ------------13. Contact Person -- ---S~L~ — ` 14. Federal Employer ID. # _ P _ s-.J 5. Tel. #. ct _ 7 O —Fax # 5 7c cS 16. Address lap -----City // J ~/ —_ State /U Zip 1L2 2 _

V. THIRD PARTY AIR MONITOR eA 17. Name ~ (G r T? S fc_18. Contact Person _~ 4 C ' 4° (" •_

19. Federal Employer ID. # P II ( 20. Tel. # 2ra=~as - 004 ?- Fax If zl a=2 2 21. Address g 1T4 ___. City L ___—_ State `t Zip 129L

22. Sample Analysis Laboratory— l L: ( ((~« h a ~`~ le c _ 23. NYS DOH ELAP

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

Asbestos work schedule 0 Monday 0 Tuesday 0 Wednesday 0 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

t t0 0 Square Feet, and/or Linear Feet 7 BUREAU Or JtP )1 WEWc iA X'AV1V;pJ%gE!lrAt 3 cat^tas uErir4PCEFAEr(r PfOCRAMarac-. mn?

NYC-WTC 000111443