NYC 9/11 Public Portal Document
J + vv DEPARTMENT OP ENVIRONMENTAL PROTECTION
v ~~~o ' ix a~+e,~N. NYC
• Asbestos Control Program
DA..~ 59-17 Junction Boulevard, 8°i Floor. Corona. NY 11388.5107 8 or TRu N
ONLY FOR FC2ALUSEONLV
TYPEWRITTEN ASBESTOS PROJECT NOTIFICATION
FORMS WILL . (ASBESTOS INSPECTION REPORT) 1.
}' ACCEp;~ :rcrte:t~.r.
F,I (See sd>edule) .
5! , w 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.
1. FACILITY ~ . ~ _
2. Address ~ LA S rT Borough Zip ---/A=) ©t)
3. Block 4. Lot
5. Type of Facility 6. Name of Building
U. BUILDING OWNER I
7. Name p
n
-C--t-- S, i E- -- i • • 8. Contact Person _._. ,l f ade~
13 P
9. Tel. # 3 " / Fax # ------------------ ---- - -----.
.._.- A1 / Zip II_0
10. Address L.~-OD t~~ ~ j . P/C ~
III. GENERAL CONTRACTOR
11. Name Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name . 'Quell CO ___13. Contact Person 7 .-Y
---
f/ /,
14. Federal Employer ID. # ~__- P11 ..-,-.-)5. Tet. # l6 7 -/ - 300o
-
Fax # 54-
16. Address . E Ju&. -a City L.) State Zip.I! ?
V. THIRD PARTY AI MONITOR
A`
17. Name ~, gig. R..4 L ZE1 . iC, i12 1, Pc 18. Contact Person Y'ltaq'fL
19. Federal Employer ID. # 20. Tel. # a (-4 " ~aa - d0' - _
Fax # a__„~ 22_O[>'j 0
21. Address 19-E (T ``'f City _ re.K State t ( '( Zip 00 t
22. Sample Analysis Laboratory ~ ly't ( «- ham$ r °x'fC-S, ('-rc 23. NYS DOH ELAP # (I q eO
VI. PROJECT INFORMATION
r-~
24. Starting date for this portion of work ~t? 2I102. Projected completion date l 1 0
Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Friday ❑ Saturday ❑ Sunday
Shift from: ❑ am 0 pm to ❑ am 0 pm
If other, 4
—
Specify :
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E `co
rri i
Access to inspect the premises must be provided during the work schedule Indicated In this Item. J } f7 ZQQZ
25. Total amount of asbestos-containing material to be abated during this work
10)50t2 Square Feet, and/or Linear Feet '
u~"
2 ~
zt ti~ ACP 7
2120ot
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4Et.~C:~tk?y 3 f•`f;c~,p~7
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NYC-WTC 000119770
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