NYC 9/11 Public Portal Document
NYC DEPARTMLWT OF. ENVIRONMENTAL PROTECTION
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Asbestos Control Program
59-17 Axis n Boulevard. 8'" Floor. Corona. NY 11368_51o7 ,ø10f ' /d' /~~~,
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TYPEWRJTTEN ASBESTOS PROJECT NOTIFICATION FOR OcFc*A USE
( FORMS WIU BE
tr ' ACCEP (ASBESTOS INSPECTION REPORT)
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When submitting this form at the NYC De of Buildings, thr: origiriai form and three (3) copies with originsl
signatures are required. Submittal at the NYCDEP requires one copy of the form
form must be submitted to the NYC DEP not less than one week in advance of the with original signatures. This
start of abatement activities.
I. FACILITY
2. Address _ t 1 t4 fZ o A-l~ t~J P ' ( Borough 1 Zip 10 O 2
AKA I I A L -1~8 3. Block S 4. Lot
5. Type or Facility 6. Name of Buiidmg
II. BUILDING OWNER
7. Name OL t'Y1 t N 1.A+a . ehLrr..c Ca a. Contact Person ALf CL. PO
9. Tel.# 'Fax #
10. Address LPr-t City State Zp OO
III. GENERAL CONTRACTOR
11. Name
Tel. #
IV. ABATEMENTCONTRACTOR
ASBESTOS
12. Name f ~1LJ'el~ t 3O f/ 13. Contact Person ~T' oT2_
14. Federal Employer l0. #ti _._._._._._._._._P u - - - - - - - - 15. Tel. # 'I 7i 3°°o Fax # J
16. Address 3010 ~(~ /, /~
Y
,
State} p1L3.
V. THIRD PARTY AII MONITOR
pp
17. Name AI.E8 J A kT(ZEQ .1J6 P<: 18. Contact Person
A
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19. Federal Employer ID. # 20. Tel. # ara - as- aOj,.Z. Fax # zra _?P42 -OF,:tom
21. Address $ JKf City _ 9i 799
State zip 00
22. Sample Analysis Laboratory _ SC{f?.rT le- L, e7417'X'tES17trc 23. NYs DOH ELAP # / £s'C
VI. PROJECT INFORMATION
24_Starting date for this portion of work O O Projected completion date 0
Asbestos work schedule D Monday ❑ Tuesday ❑ Wednesday ❑ Thursday D Friday 0 Saturday.a . Sunday
Shift from: Dam 0 pm to D am Cl pm
specify !' •
'
Ir
Access to Inspectthe premises must be provided dr*fng the work schedule kx0ceted in this
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25. Total amount of asbestos-containing material to be
abated during this work
Square Feet. and/or Linear Feet
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712001
Mks r.:rt
NYC-WTC 000122595
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