NYC 9/11 Public Portal Document
0/3 NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
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Asbestos Control Program
59-17 Junction Boulevard, 8°i Floor. Corona. NY 11368-5107 1 O3MJi
BuOdng Dept or TRU No
FOR OFFICIAL USE ONLY
ONLY
TYp ~ ASBESTOS PROJECT NOTIFICATION
F I E (ASBESTOS INSPECTION REPORT)
1 —•~wee fee ule)
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
IF 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 _ _—C I4 I'y1 ~S Borough ML — Zip C 0
AKA 3. Block -- 4. Lot
5. Type of Facility_____-- ........._. 6. Name of Building
It. BUILDING OWNER
7. Name 8. Contact Person
9. Tel. #._ ..._._. ----~_.S ax # .__--
10. Address j
III. GENERAL CONTRACTOR
11. Na Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name ( ~IL ( .1_~~U_I_._._._._._._._.,-- -__—---_13. Contact Person
I 7 ~- 3oo o
14. Federal Employer ID. #L -_! . __~_,-.l 75. Tel. # ~_—
~ -__ ,—t--_-- Fax # _-- __------__—_
/ y t'
16. Address 01v_e c~4 ~! ~' ------- City _~'.J~ 145 , State A) Zip _LLZ C[ _
V. THIRD PARTY AIR MONITOR
h } f
17. Name ~A`( Zc tZ ,r ~? S r 18. Contact Person
19. Federal Employer ID. 0. Tel. # ~(_! ~a ~G~ Fax #
21. Address L__ ~ __-- City w State L~ Zip LL_
22. Sam le Analysis Laboratory (> ( (F(C—_G~ -A ?'!~S J — 23. NYS DOH ELAP #
VI. PROJECT INFORMATION
24.. Starting date for this portion of work _ 6 /L /b? Projected completion date __7_/2__L'_2_—
Asbestos work schedule ❑ Monday ❑ Tuesday O Wednesday ❑ Thursday ❑ Friday ❑ Saturday ❑ Sunday
Shift from: ❑ am ❑ pm to _--__ ❑ am ❑ pm
,2 4,
If other,
specify _ _ _ _--
Access to inspect the premises must be provided during the work schedule indicated in this item.
25. Total amount of asbestos-containing material to be abated during this work
J1_4.. ?___ Square Feet, and/or ___-- Linear Feet
Is- 0115
C. I
NYC-WTC 000122176
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