Asbestos project notification form, Oct 2001

NYC 9/11 Public Portal Document

G1tOf, NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION +`O~' ~~• Asbestos Control Program Ar 59-17 Junction Boulevard, 8th Floor, Corona, NY 11368-5107 OCTRU ONLY FOR OFFICIAL SE ONLY TYPEWRITTEN f'" ASBESTOS PROJECT NOTIFICATION FORMS WILL BE - `` (ASBESTOS INSPECTION REPORT) ACCEPTED """:"-VC 6v,/4.r. (See tee 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 .

1. FACILITY //J~ 2. Address _,~L_&il L O A D vJ A( Borough t Zip )C O )c

AKA — - 3. Block 4. Lot

5. Type of Facility — 6. Name of Building II. BUILDING OWNER t; S3 n^ 7. Name i~bA tV ~I~ OC ' 8. Contact Person jth 2..1

9. Tel. #c 7S L 7 ax#

10. Address T \1E 5& ' _ s i -- City State ' Zip ~O

I11. GENERAL CONTRACTOR

11. Name_----- _ — -- Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name 'eft ~-~_> .~._._._._._._._ _—_13. Contact Person /c '-) OfL.f 14. Federal Employer ID. # _` —~ _._. P I I ? 15. Tel. # J ! 6 - 7~t_ 300 0 Fax

16. Address oc~ v~ v~ City _ State IJ V, Zip iL22?

V. THIRD PARTY Alit MONITOR

17. Name A'i (ZEtz /.IGr ~S C 18. Contact Person ~ 1! - ' ~^

19. Federal Employer ID. # _P11 — 20. Tel # - ooh Fax # a=~~ -06 O

21. Address ~2 — f City AkW State) Y_ Zip _LOO

22. Sample Analysis Laboratory— S~=(fl`-r (F«— t^ *6 6 r —A c 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 0 pm to 0 am 0 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 „ JtP :'CrA7heY i~~ :'i4~f1,T t,tc_ i5S G;;;Pa tRn,

NYC-WTC 000111388