Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION a Asbestos Control Program 59-17 Junction Boulevard, 8'" Floor, Corona, NY 11368-5107 — - — ONLY D A t1~ ~~ ASBESTOS PROJECT NOTIFICATION Building Dept. or TRU No FOR OFFICIAL USE ONLY TYPEWRITTEN % ~~ FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1 ACCEPTED -.--"="-Y< _°'"•~. (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 _ — P S i - L Borough _' `— Zip - t 00 t ^-y1 AKA ~~~ S j -- _ 3. Block 4. Lot _ --

5. Type of Facility_____-----r _ ---- 6. Name of Building — II. BUILDING OWNER

7. Name ` ~/~1S ~1 ~~1rJ~~- C- ~ 8. Contact Person _ _______

9. Tel. # Fax# _-- -- .l 10. Address %a-~-- -------- ( ~~~ 1 (~ City ---L—~ ------ State N' OO Zip _LO —

III. GENERAL CONTRACTOR

11. Name Tel. # ------~—

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ~O f L -C ~_O _ _ _ __ __ --`---- 13. Contact Person _ ~ /`~ C ~L/I _ P~~ _ _ _ _N_ C 14. Federal Employer ID. # i _ X15. Tel. # ct 16 - 7~l -36>0 o Fax # si 3d~•5

16. Address old~ !>? i~__---- City -- ~______ State /J I Zip _LZ~

V. THIRD PARTY AIR MONITOR

17. Name t V ZC Ci r ~ S C_18. Contact Person - ± ("

19. Federal Employer ID. # _ _. 20. Tel. # a f =~aa - 00~_ Fax # 2/a=~a -06O

21. Address g --- City t State Zip

22. Sample Analysis Laboratory <=~~ /~« ~^ * a ~W«S '1 23. NYS DOH ELAP # _•LtY 9S d _

VI. PROJECT INFORMATION 24.. Starting date for this portion of work Projected completion date r --,~ I--,

Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ 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

Square Feet, and/or Linear Feet

31 B!JP.EAU OF ENYiRO4MENT EAECiANGN S Q;ruRCEMEW 4d'c;rOS Cr,;~ rNOI P111 "AM mit

NYC-WTC 000111446