NYC 9/11 Public Portal Document
NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
Asbestos Control Program
59-17 Junction Boulevard, 8ei Floor. Corona, NY 11368-5107 tf4' o Tfr Building De or TRU o
FOR OFFICIAL USE ONLY
ASBESTOS PROJECT NOTIFICATION
~r `'!iion
BE (ASBESTOS INSPECTION REPORT) i.±kLC ( tee 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 05 t On g€-fib S T Borough " I Zip (O 0 (3
AKA 3. Block 4. Lot _L _
5. Type of Facility 6. Name of Building
II. BUILDING OWNER
A1
7. Name [r
~`! V it \L.. 8. Contact Person ' Y`"' r t C Th+FL—
q
9. Tel.# #
10. Address _.LQS I tom— ___ 5__ -- City __±L_ Staten=j Zip
Ill. GENERAL CONTRACTOR
11. Name_------ -- — Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name Ee c 3 1CO ------ __13. Contact Person _ ~ G L/9
14. Federal Employer ID. #J. P11 15. Tel. # ~( 6 - 7 -f -3Oo o Fax # SL 7&- des
j 16. Address O CJ -- - City J /!7V( / _ State N Zip IL? ç:3_
) j
V. THIRD PARTY A{AIR MONITOR
A
17. Name V~ 2 kN. 2'-E tZ IG r ?S r~jC 18. Contact Person ~~ L ('~r (^
19. Federal Employer ID. # _____
20. Tel. # a r3=~aa - ooh Fax # 213 - 4i 2a - 0 6 .30
21. Address ~~ gk~1 City ~`E ~1=(IC State j Zip (00 ( .
22. Sample Analysis Laboratory— C f ar(~S J " 23. NYS DOH ELAP # _
VI. PROJECT INFORMATION
24_ Starting date for this portion of work
I
2' •'I 0 Z Projected completion date _aJ Jo'a.
Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Friday ❑ 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. Z
25. Total amount of asbestos-containing material to be abated during this work
C',
"7I 5 Square Feet, and/or Linear Feet
ACP:
21200
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NYC-WTC 000114598
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