NYC 9/11 Public Portal Document
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signatures are required. Submittal
form must be submitted to the NYC I =
I. FACILITY
2. Address l
AKA
5. Type of Facility__ 1
II. BUILDING OWNER
7. Name V Vl TV \4'L-- 8. Contact Person tla- t N I mT'
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9. Tel. # tz 9 4t #
10. Address L~ ~~ S _ City__ N= State'v1 Zip _ _100 13
Ill. GENERAL CONTRACTOR
11. Name _ Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name .J A ?ie /'C0 _,_____13. Contact Person /c? jkL/
14. Federal Employer ID. #t- __,P ll ------y1J15. Tel. # _iiJ _2AiL3c0 0 Fax # _ I _2./3d8S
J 16. Address City _ State N Zip JIZ 3
V. THIRD PARTY AIR MONITOR
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17. Name ( ~j Zt: NG°_~ rC 18. Contact Person Y t L-
19. Federal Employer ID. #_____.._ __ 20. Tel. # a (~=1aa - O Fax # Lid ? 'Off, 3 D
21. Address { City W`~'~~ ~ State ~ Zip 00
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22. Sample Analysis Laboratory__ .( r f (~i- h C (£5 J 23. NYS DOH ELAP # _ii g~
VI. PROJECT INFORMATION
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24.. Starting date for this portion of work ~ 2'1 10Z Projected completion date _j. _O 2.
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• Asbestos work schedule 0 Monday 0 Tuesday ❑ Wednesday ❑ Thursday ❑ Friday ❑ Saturday ❑ Sunday
Shift from: ❑ am ❑ pm to ❑ am ❑ pm
If other,
specify _-- _ I'~CI1'At
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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
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15 Square Feet, and/or Linear Feet r~UG
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NYC-WTC 000114597
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