NYC 9/11 Public Portal Document
O/'/ ü1i 0 NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
~P
4 Asbestos Control Program
59-17 Junction Boulevard, 8ei Floor. Corona, NY 11368-5107 ('P")7U b!ThL
Building Dept. or TRU Ao
V
FOR OFFICIAL USE ONLY
ASBESTOS PROJECT NOTIFICATION
BE (ASBESTOS INSPECTION REPORT) 1. Li, ,C
(See fee sdiedule)
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 '° tO T Borough "1 Zip (O O (3
AKA 3. Block 4. Lot -
5. Type of Facility_— 6. Name of Building
II. BUILDING OWNER
At
7. Name WL. 8. Contact Person ' Y` °"d h t C —
9.Tel.# _ t #
10. Address _ LQ _Li 5 _— City __j T Stated Zip r o 013
Ill. GENERAL CONTRACTOR
11. Name_------ -- — Tel. # — --
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name £'e GY`' I IO ------- __13. Contact Person L/
14. Federal Employer ID. # ,j. ' 11 115. Tel. # (6 - 7('300 0 Fax #
16. Address _P1 24) ---- City ±1 L57 _ State N Zip I? 3_
V. THIRD PARTY AIRMONITOR
17. Name 1~~ e Zt Q 6 i 1' r~j C 18. Contact Person 1% t C L ( .r (^
19. Federal Employer ID. # ~p
20. Tel. # a [3-1aop --
— Fax # ai 2,9 - 06.30
21. Address ~~ g k~1 ' ~= City IL 12t. State - _ Zip .1 00
/
22. Sample Analysis Laboratory_._ ( ((~(C- 23. NYS DOH ELAP # _ i' / g g-0
VI. PROJECT INFORMATION
24_ Starting date for this portion of work 2' 0 Z Projected completion date —$ 3~
Asbestos work schedu e ❑Monday ❑Tuesday ❑Wednesday ❑Thursday ❑Friday ❑Saturday ❑ Sunday
Shift from: ❑ am ❑ pm to ❑ am ❑ pm / " 1 Z)
If other,
_ —
Access to inspect the premises must be provided during the work schedule indicated in this item. (ANJI
25. Total amount of asbestos-containing material to be abated during this work
Square Feet, and/or Linear Feet
:
0
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NYC-WTC 000114598
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