Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION ,.`•° . Asbestos Control Program 59-17 Junction Boulevard, 8"' Floor, Corona, NY 11368-5107 — FOR OFFICIAL USE ONLY° -- 1 ONLY TYPEWRITTEN ~~NM~Nr~ Rc~° ASBESTOS PROJECT NOTIFICATION P FORMS WILL BE (ASBESTOS INSPECTION REPORT) 1. ACCEPTED """ ""` 3°Y~"`~. (See feesehedulej

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 .

FACILITY r 2. Address _ ] —~ — 1 M-. Borough —)tSl; Zip

AKA —_I L_C H C L_ C ZT 3. Block 4. Lot ---

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

7. Name c C. t OrtES fi JC 8. Contact Person ----

9. Tel. # I "4JJ 7 Fax # _-- —

10. Address off- LO I 1 City r~ - —_ State `~ Zip

III. GENERAL CONTRACTOR

11. Name_— _— Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name L~i` __ --- ----- ----_13. Contact Person Q1J ` c 14. Federal Employer ID. # l ------ PI'I- ~15. Tel. # c1 ^'3~ 6 ~~! 3dcs Fax # ----------- J~ — 16. Address _201 lt .LV ___ City —__ / ~/ _--_ State N zip 1L22. _

V. THIRD PARTY Al€t MONITOR nA l f 17. Name _ /f_) -S..-.P!t7`( 2 . NG rA ~? 5 ff - 18. Contact Person _ rYtlGcEl- +mil GI"!

19. Federal Employer I0. #_ = P II 20. Tel. # Fax # a =/ _ . 21. Address g L 'ur City ___ State L-~ _ Zip

22. Sample Analysis Laboratory— C(-E~-c((,C(L G-/6a '«S c P~ — 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 ❑ 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 S e~~ Square Feet, and/or________ Linear Feet 7 WM Or Efr.'IRo JM P "F;'-WazO.a 1 ErFrP.CEM&%T 4saara; Cr!,ROL rpn

NYC-WTC 000111447