NYC 9/11 Public Portal Document
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,~, NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
~. Asbestos Control Program
59-17 JuncUdfl Boulevard. 8°i Floor, Corona, NY 11368-5107
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Building Dept., or TRU No
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TYPEWRI ~~` ASBESTOS PROJECT NOTIFICATION
(ASBESTOS INSPECTION REPORT) I
--- (S 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 9 EAbE S (~~ €. T Borough Zip
AKA 3. Block 4. Lot o~-•
5. Type of Facility --- 6. Name of Building
II. BUILDING OWNER
7. Name M-~ V ,-s - (1 z- 8. Contact Person t' ' Nl,osLo WtTZ-
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9. Tel.#~3~{ 1"3 ) Fax#
10. Address PII — City --- State _
Ill. GENERAL CONTRACTOR
11. Name____.._..___________________________---- Tel. # —
IV. ASBESTOS ABATEMENT CONTRACTOR
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12. Name _ ~ IL w_ _ _ _v~ 'I_
_~_._._._._._._._._.~------ 13. Contact Person _____
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14. Federal Employer ID. #~_-,_._._._._,_._._._._,.~. # --Tel.
——/- 7, ,~L'-3060
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6~V Fax # ---~ --- S1-7W-3dt~5
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16. Address ~ (~ 1 vr — City _/ 1 _State ~/ Zip ILZ c?
V. THIRD PARTY AIR MONITOR
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(4 18. Contact Person I1t~ t 1. o L ll-r1
17. Name. ~ R .t rt Zt !L G i~I ~ S . pC —
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19. Federal Employer ID. # ___-----_ 20. Tel. # a ~~ Laa - OO — Fax # 2.I3 r 2a - 0
21. Address ~ _g'E 1-1L1 r { City W-610 -Cr- State 1_ Zip 00
22. Sample Analysis Laboratory— -( 7fI« 1 t4i3c ~
(ES vc 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 ❑ Wednesday ❑ Thursday 0 Friday ❑ Saturday:D Sunday
Shift from: ❑ am 0 pm to ❑ am ❑ pm i 18 1
If other, co
specify --- — Rrt•t.n/o
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Access to inspect the premises must be provided during the work schedule indicated in this item.
J J L 2 62002
2002
25. Total amount of asbestos-containing material to be abated during,this work `° %~t!`:1
S O 2 i?Al. -
Square Feet, and/or Linear Feet ~RU; 1,
ACP
21200
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NYC-WTC 000114520
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