NYC 9/11 Public Portal Document
NYC DEPARTMENT OF ENVIRONMENTAL PROTECTIO
Asbestos Control Program
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59-17 Junction Boulevard. V Floor. Corona. NY 11358.5j97 (,
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ASBESTOS PROJECT NOTIFICATION (~
(ASBESTOS INSPECTION REPORT)
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When submitting this form at the NYC Department of 8u8du~gs. 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 rat tens than one week in advance of the start of abatement activities.
L FACILITY
2. Address B -/G Borough _1 0 O&
AKA — S J p/i 10 ` 3. Blodc._.~Q 4. Lot
5. Type of Facility 6. Name of Building
U. BUILDING OWNER
_._._._._._._._._._._._._._
7. Name ~ W 8. Contact Personi P11
9. Tel.# _ Y
10. Addres~._._._._.~ PII y PI I State PII P11
Ill. GENERAL CONTRACTOR
11. Name Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name.1L3 13. Contact Person 7 -) (l Sj,1_
14. Federal Employer ID. #J P11 X15. Tel. # 616 - 7-/ - 3 00 d Fax #
16. Address J 0! b e City 0_9 3l State MD -112 G
V. THIRD PARTY Alf MONITOR
17. Name R$~t *74 ZErL. G rAI S Pc 18. Contact Person t1 4*EL
19. Federal Employer ID. # 20. Tel. # 0 0 - 99d- 00i -_ Fax # ,2f c3_- 2-0 "o
21. Address 190 rtS1 ' S'( f ( CityI( 34. rQ2 00
State Zip
/
22. Sample Analysis Laboratory SC(E 1 (C- __t t 7z4'!~K't£S17~rC _ 23. NYS DOH ELAP # _ _ (I 'I FS .
VI. PROJECT INFORMATION
24 Starlingdate for this portion of work !o/2 ,t/O2_ er ected completion date 6
Asbestos work schedule D Monday D Tuesday D Wednesday D Thursday D Friday ❑ Saturday ❑ Sunday
Shift from: Dam D pm to Dam Cl pm
If other.
specify
Access to hrspect the premises must be provided d *,g the work schedule Indketed hr this Item.
25. Total amount of asbestos-containing Material to be abated during this work
(1, Ss Square Feel, and/or Lfiear Feet
ACP 7
28001
NYC-WTC 000115836
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