Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program OM " 59-17 Junction Boulevard, 8'" Floor, Corona, NY 11368-5107 Building Capt. or TRU No ONLY ~ ya° .p FOR OFFICIAL USE ONLY TYPEWRITTEN c ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) 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 _Q0 _c 1 ..EE, T Borough N -- Zip

AKA 3. Block 4. Lot __—_---

5. Type of Facility____-- ___ 6. Name of Building II. BUILDING OWNER

Name _—_~- —____ —_ 8. Contact Person

9. Tel. # Fax #

10. Address 2g H P /€- Ju . City N ~~C State J L Zip III. GENERAL CONTRACTOR

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

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ell _~_ J0 1I c?L --------- —_ 13. Contact Person --, . 14. Federal Employer I0. # _ j_== x~ ~--- - I 15. Tel. # _ 7 -1-300 0 Fax #

16. Address Q1~ ------- City / 7 f'L_—_ State /~ Zip

V. THIRD PARTY AIRMONITOR ,~ r 17. Name JA2U S kr(Zr a G 1!lt' ? 18. Contact Person

19. Federal Employer I0. # _____—_— —_ 20. Tel. # ~(~=~aa - 2~ — Fax

21. Address L '~ ~ City ~'€k?~C State ~_ Zip -00 `

22. Sample Analysis Laboratory— S'C( P' ((~t~- t!Alga ! '(E'S 23. NYS DOH ELAP # _11 ___

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

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

Shift from: __-- 0 am 0 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

Square Feet, and/or _________ Linear Feet 7 11 97EA(I Or ?«'6ECt;.itf.-vEM11R11Mc11TAt 3 Erf:a.CEfAE~7 4.'K:; sCr!rpC4 P';PaPAAI roll y

NYC-WTC 000111444