Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

.. . Ot1A o".~;TY . NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION .~ . N. Asbestos Control Program 59-17 Junction Boulevard, 8"' Floor, Corona, NY 11368-5107 — — No ONLY BuildingROFFIICAL SE ON TYPEWRITTEN ''.voN,~fNrwoaon°°'r ASBESTOS PROJECT NOTIFICATION FORMS WILL BE ar/e< (ASBESTOS INSPECTION REPORT) 1 ACCEPTED _.ww:^ve o r, (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 _LL __ -O/ .b1,JA -- __ Borough N "(-- Zip __t 00'OL_

AKA_ ____....... . _ 3. Block 4. Lot

5. Type of Facility 6. Name of Building II. BUILDING OWNER

7. Name l 1 8. Contact Person

9. Tel. # ~-~-41 o2-(O *7- ?~a Fax #

10. Address _L ~t___ LIo S --__ City __~~±` ~L_---M State ,1v ' / Zip

III. GENERAL CONTRACTOR

11. Name_ __ __ ____-- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name _ (€e { Q3/iCCL 13. Contact Person

14. Federal Employer ID. #_6 15. Tel. # J - 7~~ -300 0 Fax #

16. Address 0/(D ~ city I I/ State 10 zip V. THIRD PARTY AIR MONITOR

17. Name _i1~?~ _ kre ZEt2 /.f61 '1 S+fc_18. Contact Person

19. Federal Employer ID. # .y,_._._._._. PII 20. Tel. # Fax

21. Address s~ g>( 21{1 — City LI`~ —N _ State ~ Zip

22. Sample Analysis Laboratory_ e_(-f ((FLL h 6 (-r'' ~e s J" — 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: 0 am ❑ 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

3 7 (o Square Feet, and/or ___ Linear Feet ,7 BUP.EAU or ENYIROMO 31 Cuiu R EKWP.0 M,AL T 4 8ZSrOS CC4TRCI PfiOCRAAI 1Q11j

NYC-WTC 000111449