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 — Buidi No ONLY D~~ FOR OFFICIAL USE ONLY TYPEWRITTEN ff°NMfNfw n ~< ~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED _'":^re7i':~°.C. - - (See fea 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 NYCOEP 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 r _ 2. Address _ `~' —W --- ~T Borough —_I')_ 'L— Zip

AKA —__------ --- —_ 3. Block ----

5. Type of Facility—_-------------- 6. Name of Building

II. BUILDING OWNER P 8. Contact Person ------- 7. Name - -- II -----„~,~~ ----- 9. Tel. # ---__----,._ _ Fax ._

10. Address__ _ ~P.~ _._._._._._._._._._._._? Cib —eMt1=i~ _ state P_

III. GENERAL CONTRACTOR

11. Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR _ l 12. Name ( -------- —13. Contact Person

14, Federal Employer ID. # _._._._._._._._.P _._._. 3oa 0 11 ._._._._._._. 115. Tel. # J + - 7t~~—--- Fax # --/__) , 16. Address _ 01c~.8 12" -- — — City J / L/ —_ State N Zip _flL2 _

V. THIRD PARTY AIR MONITOR

17. Name ___1 ~ L_ S fc—_18. Contact Person

19. Federal Employer ID. # P 1 } 20. Tel. # a ~~=1aa - OQ — Fax #

21. Address g > L ` ~{ — City €I^? ---_ State _Zip _LDO L_

22. Sample Analysis Laboratory— S(f ((1(C LA 6 <`~'(ES uc — 23. NYS DOH ELAP # _L/_ . VI. PROJECT INFORMATION 24_Starting date for this portion of work ________--_ Projected completion date r -1 r -I 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

Square Feet, and/or _ Linear Feet 7 BUREAU or ErryPO,IA!ENTAL i '0.1& ERFMRCEME 1 4 cTOSCCMrRGL P6CCRAM till 2

NYC-WTC 000111448