NYC 9/11 Public Portal Document
NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
Asbestos Control Program
W17 Junction Boulevard, 8" Floor, Corona. NY 11368-5107
6ufd nQ Dept or TRU No
FOR oFnC*AL USE ONLY
ASBESTOS PROJECT NOTIFICATION
(ASBESTOS INSPECTION REPORT) iii
to adwdule)
When submitting this form at the NYC Department ci 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 rat Tess than one week in advance of the start of abatement activities .
I. FACILITY
2. Address _fl b G ,t 9, A
~& Borough Zip10(70
AKA 3. Block I >Qv 4. Lot
-
5. Type of Facility_______________________________ 6. Name of Building
IL BUILDING OWNER
7. Name St_ -Q-~e-'r S. Contact Person
9. Tel.# Fax#
10. Address 1 tj ^3 a- 3~ A City _State 13_ 'jzp1 t. S 1f
III. GENERAL CONTRACTOR
11. Name Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name - F ' /JE1L 1_13. Contact Person 7 ) 11' `—
14. Federal Employer ID. # P11 15 Tel # c1 ~/- ' 300 O Fax # I - ?~ J ~S
/Q 7' .~~
I"
16. Address 20/b it ?(J~/ S e City _State 13 ' Zip If? i'.
V. THIRD PARTY AI MONITOR
o `l
17. Name I_ A A t Z.E G i S, Pc 18. Contact Person A'~t"' L (mil 0 Lh 4
19. Federal Employer ID. # 20. Tel. # a(- 9aa . OOf-' Fax # 2L9 2a -O6 7jO
4
21. Address g kS( l id City IY'~w t?-f~ State Zip
22. Sample Analysis Laboratory SCt 1 4'- 1ESj Aar 23. NYS DOH ELAP # /' O .
VI. PROJECT INFORMATION
24_Starting date for this portion of work ~- Projected completion date 1O OY
Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday 0 Thursday ❑ Friday ❑ Saturday Sunday
Shift from: ❑am0pm to 0am0pm
1
If other. f
specify
RECEIVED
Access to inspect the premises must be provided during the work schedule indicated in this Item. t SEP 13 0(r2
n~
aEfIVjR~R\IF~Rfr,
25. Total amount of asbestos-containing material to be abated during this work AMY RENfL1P,Cf. w
ASBE ROGCONiu
'..
Ig S Square Feet, and/or Linear Feet
Qu a PROf•RM'
7
snow
NYC-WTC 000121884
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