NYC 9111 Public Portal Document
PROTECTION O
NYC DEPARTMENT OF ENVIRONS•
Asbestos Control Program
11368.3107
59.17 .unction Boulevard. 6" Floor, Corona, NY sup Dept, er TRU 14
FOR OFrom. UK ONLY
EtNRi7TEK
ASBESTOS PROJECT NOTIFICATION
t (ASBESTOS INSPECTION REPORT) 1. C
FORMS W11.L SE f$ tchoa+ilel
ACCEPTED ••• ^.rS:iL+~itr.
v4th orteinal •
(he Original forth and three (3) copies
When submitthig this form at the NYC Qepertatent of Buildings; 01 the 100m 'M1h odgkia) srgnatUfst. This
Submittal at the NYCOEP requires one copy
signatures are required.
week In advance of the start of abatement aclMtles .
form must be submitted to the NYC DEP not less than one
1. FACILITY `_
r~ Borough — ___ Zip
2. Address _~ l '~
3. Block 4. Lot
AKA _L
5. Type of Facility___— — .—~..8. Name of Building _______-__-
8• Contact Person
7. Name
9. Tel. # ___--_.— — Fax # _ __.__.-
City State __,.-.~ Zip ..---
10. Address
Ill. GENERAL CONTRACTOR
-- Tel. #
11. Name___--____—_--- - ------
IV. ASBESTOS ABATEMENT CONTRACTOR -Tam ,n ~
13. Contact Person —
12. Name Wf ` ' G-1- -------
`" _ 30 J
Fax # __-~--- rw% S
14. Federal Employer ID # ' P'~ _ 15. Tel. # I r 7i ~-_— 0 0
City 1/L' -- State (~ Zip IL? 1 -
16 Address
V. THIRD PARTY AI MONITOR
____
17. Name .J&
ltf) R~•f
.w.__
Gr S+,L_18.ContactPerson
,tr
q 3D
c1a -- Fax # —r f 22_
Employer 1Q. #_..________. 20. Tel. # f o - 1
19, Federal
-- State i zip
21. Address 8~ ------ City ~-
~ A 7~(~S arc ^ 23. NYS OOH ELAP #
22. Sample Analysis Laboratory—_ It7`~~(«-1~ 0
VI. PROJECT INFORMATION Q
Z Projected completion date
24.Starting date for this portion of work
0 Monday 0 Tuesday 0 Wednesday 0 Thursday
0 Friday ❑.Saturday
Asbestos work schedule
Shift from, __ D em ❑ pm to ©am ❑ Pm
If other.
specify _--------- -- — .._ - . R~vEO
work schedule indicated in this item. JUN 28
Access to inspect the premises must be provided during the 2002
`P/BANHM
abated during this work ~.
25. Total amount of asbestos-containing material to be MOGRAM
Square Feet, and/or Linear Feet
ACP 7
212001
unr ~LtrT-t9~-ZIZ: Xl?J i3J3 d34
TT •a P7: T T OOZ 8'
NYC-WTC 000114743
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