NYC 9/11 Public Portal Document
4
NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
Asbestos Control Program
{ 59-17 Junction Boulevard. 8e Floor, Corona, NY 11368-5107
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Building Dept. or TRU N
FOR OFFICIAL USE ONLY
ITTEN ,~ Mrtiriio~~cdt ASBESTOS PROJECT NOTIFICATION
MS WILL BE (ASBESTOS INSPECTION REPORT) 1.
ACCEPTED -"'•~r~.~.•t4~
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 _ I O ~~~ ~~ €_T Borough Zip 1. 0 0
AKA 3. Block _I y' 4. Lot 7 3
5. Type of Facility 6. Name of Building
II. BUILDING OWNER
7. Name I ©g 1- ett - t ~ -,,o_ • Contact Person
9. Tel.# ~©~— Fax#
10. Address L fl~ --eS` City — IJ ~_ State N' Zip Ob
III. GENERAL CONTRACTOR
11. Name __----- --_ Tel. # — —
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name _ ___
(____________ 13. Contact Person
-----P11 --d ~/ 1 ✓ dU
14. Federal Employer ID. # L.L ,_ __ -
, 15. Tel. # __--_---- p Fax # _ Ls
16. Address o1c~ (> v~_------ City J / l~T _ State N 1 Zip IL? ~r
V. THIRD PARTY AIR MONITOR
V41tLt{~-E(, t~°L
j , r
17. Name t-v~ Zt LZ Gi l?S rC
~h 18. Contact Person
19. Federal Employer ID. # ___--- 20. Tel. # 13~a2 - 0 O ' Fax # 2a 2,92 -06 30
21. Address FE 7 City State L- Zip
0o(~1
22. Sample Analysis Laboratory__ -( i7 L _' E ~a ES cf 23. NYS DOH ELAP # _ if ~y
VI. PROJECT INFORMATION
24.. Starting date for this portion of work _ 02_ Projected completion date QI 0 2.
30J_
Asbestos work schedule ❑ Monday ❑ Tuesday 0 Wednesday ❑ Thursday ❑ Friday ❑ Saturday ❑ Sunday
Shift from: ❑ am ❑ pm to ❑ am ❑ pm
S
If other,
specify CV ~7VFD J
Access to inspect the premises must be provided during the work schedule indicated in this item. .1UN ? 4
2002
4Sj RANNM cb
25. Total amount of asbestos-containing material to be abated during this work
r ROCMNf ~'
Linear Feet 211C
SO Square Feet, and/or ... o
F7 J AI E'
l I ?- : 7OC
P6 f,~A;;fl
1rn7
NYC-WTC 000114557
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