Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION cTr ocrAir DA r~ Asbestos Control Program 59-17 Junction Boulevard, 8"' Floor. Corona, NY 11368-5107 Building Dept. or TRU No FOR OFFICIAL USE ONLY ' l ONLY TYPEWRITTEN f'~%~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE - • ~° (ASBESTOS INSPECTION REPORT) 1. ACCEPTED ww ^YS iaae<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 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 .

FACILITY

2. Address Lfl— O~0 — — Borough A__ Zip O 21 —_

3. Block 4. Lot

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

7. Name CC AJ (U_ IG • 8. Contact Person

9.Tel,4a'M _foTh 72~7d Fax# __ __-

10. Address _ 1 ~__ 1J —~ V- — g I Q-8 City -- * j---- State _NLf Zip

III. GENERAL CONTRACTOR

11. Name_--___. .__ --------- - Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name (~IL I.CJ -~._.lS. .~._._._._._. ------C- —_, ---13. Contact Person

14. Federal Employer ID. # PII l5. Tel. # c3 « -1 ' 62 Fax #

16. Address -3ol~U(> y~ ------ City ~/ —_ State /v Zip iL2~'

V. THIRD PARTY AIR MONITOR t ,r 17. Name f 2 kr(ZE2 IG 18. Contact Person 19. Federal Employer ID. # , P~~ 20. Tel. # a_~ Laa -0O ~ ~ Fax # -I=a=G~ _ 21. Address 1__ S 2 -- City _l~` EY'~C --_ State _ Zip 10O

22. Sample Analysis Laboratory J ((f« h A6 a P tLS ~_ — 23. NYS DOH ELAP # _.L c2 ___

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

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

Shift from: __-- 0 am 0 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

aZ — Square Feet, and/or _— Linear Feet 7 BJ?EAU .1r Et19p~,y}fcNTAt ]1 VE;d C!:.1Cv i E~7tJ~CENcH► snr.ll xI rnu ~

NYC-WTC 000111450