NYC 9/11 Public Portal Document
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When submitting this form at the Nl ,
signatures are required. Submittal
form must be submitted to the NYC I = i _
I. FACILITY
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2. Address l 0 5 _ , • 'I _ .
AKA t r _
5. Type of Facility__ 1
II. BUILDING OWNER
7. Name V1 4'C--_ 8. Contact Person
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9. Tel. # t t '.4 — - #
10. Address _L ~~ 1— S _ City N ^ State 1 Zip _ r o0_.
III. GENERAL CONTRACTOR
11. Name _ Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name,... e C 7 ~U _ _____13. Contact Person _ / 1 ~ L/
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14. Federal Employer ID. # L._._._._._._._._._._._._. ._._._._._._._._ 5. Te1. # ___' 7~~ ' 3 ~ 0 o Fax # ____ 7~
JI 385
16. Address o1~ v i~ City JI 16 7 _ State N Zip if? _3
V. THIRD PARTY AIR MONITOR
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17. Name ~~~ 2&J N~?1 A
PS r~jC 18. Contact Person
19. Federal Employer ID. #______._ -- 20. Tel. # a (3=~aa - 00J T Fax # 2J3 _¶O22 -03o
21. Address ~ g 1 ' ~ City ~El± State ~-` Zip _ OO
22. Sample Analysis Laboratory_ SC-(E?L( (~~~—h / t ~''_(~ 5 J 23. NYS DOH ELAP # if /
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VI. PROJECT INFORMATION
24,. Starting date for this portion of work 2 10Z Projected completion date _J O_ f
Asbestos work schedule O Monday 0 Tuesday ❑ Wednesday ❑ Thursday ❑ Friday ❑ Saturday ❑ Sunday
Shift from: ~ ❑ am ❑ pm to ❑ am ❑ pm
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• If other,
specify ___ _ _
Access to inspect the premises must be provided during the work schedule indicated in this item.
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25. Total amount of asbestos-containing material to be abated during this work
PR0~F~0
1_ 5 Square Feet, and/or Linear Feet
21200
46S::C[ar.'.M 3 `-~f J~CEFttAT
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NYC-WTC 000114597
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