NYC 9/11 Public Portal Document
NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
` Asbestos Cdhtrol Program
59-17 Junction Boulevard, 8"' Floor, Corona, NY 11368-5107
.4. LoBuilding Dept. or
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FOR OFFICIAL USE ONLY
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ASBESTOS PROJECT NOTIFICATION
(ASBESTOS INSPECTION REPORT) 1.
W 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 n1 R
1---y =----- y - 1 ----
Borough Jam(— — Zip -------
AKA — - ----- -- ---------- 3. Block ------ 4. Lot -------
5. Type of Facility_____-- _ --------_ --- 6. Name of Building ----
II. BUILDING OWNER
7. Name _ — )tj2 -- - S C~I LI4 '8. Contact Person
~..
9. Tel. # _ _------------ Fax # -------------
10. Address Ii 3~' W _ A-bI A City __L __ A zip
State .LA
III. GENERAL CONTRACTOR
11. Name-------------------------------------------- Tel. # ----------------
IV. ASBESTOS ABATEMENT CONTRACTOR
~ /
12. Name _r(a:Dt
— ~~`'= / j (.-.-.-.-.-.-.-.-. __ ----13. Contact Person c -) /✓-r /%
14. Federal Employer ID. #1 P11 C
.15. Tel. # J 1 - 7 ~--
~ 13v6
--- d
/
------------------
16. Address 01~_ _v_ 1 v_~_--__--- City State /v Zip 1L22_
V. THIRD PARTY AIR MONITOR
17. Name J v Al ~jC
rh 18. Contact Person _ ELI L '
19. Federal Employer ID. # P11 L 20. Tel. # Q~ _ ~~a =2Q — Fax
21. Address 'kL--~ City 1W ____—_ State L' ~ Zip _~0
r2--- (- -
22. Sample Analysis Laboratory____ ( ((i( — tJL C r- A 7 °~-'I~S u' ± — 23. NYS DOH ELAP #
VI. PROJECT INFORMATION
24.. Starting date for this portion of work (_ O Projected completion date __2
Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Friday 0 Saturday ❑ Sunday
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.
J U L J 2 2002 (71
DEP/BANHM
25. Total amount of asbestos-containing material to be abated during this work O
4SPROGRAMk
l — Square Feet, and/or _—_—_ Linear Feet TRIG
ACP 7
212001
NYC-WTC 000113168
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