Asbestos project notification form header, Oct 2001

NYC 9/11 Public Portal Document r.

c„ y 0 NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION r' r+r Asbestos Control Program hhhhu1p 59-17 Junction Boulevard, 81t Floor, Corona, NY 11368-5107 Building Dept. or TRU No ONLY 00w FOR OFFICIAL USE ONLY TYPEWRITTEN M~ ASBESTOS PROJECT NOTIFICATION FORMS WILL BE (ASBESTOS INSPECTION REPORT) ACCEPTED --- ^ •so. tae 1 (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 Dopy 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 17 Ann St Borough Manhattan Zip

AKA 3. Block 90 4. Lot 23

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

7. Name 17 Ann St Corp 8. Contact Person 9. Tel. # Fax #

10. Address City State Zip

Ill. GENERAL CONTRACTOR

11. Name Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name Benjamin Kurzban & Son Control 13. Contact Person Louie lannico 14. Federal Employer ID. ll _ _ P11 15. Tel. # (718) 531-2900 Fax# (718) 209-1808 16. Address 1248 Ralph Avenue City Brooklyn State NY Zip 11236

V. THIRD PARTY AIR MONITOR

17. Name Warren & Panza 18. Contact Person

19. Federal Employer ID. at ------P11 ------- 20. Tel. # (212) 922-0077 Fax# (212) 922-0630 21. Address 228 East 45th St City New York State NY Zip 10017

22. Sample Analysis Laboratory 23. NYS DOH ELAP #

VI. PROJECT INFORMATION 24. Starting date for this portion of work Projected completion date r--~ Asbestos work schedule ❑ Monday ❑ 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 32.5 6' Square Feet, and/or 0 Linear Feet

NYC-WTC 000111529