NYC 9/11 Public Portal Document
- E
NYC 19EPARTMaN+T OF ENVIRONMENTAL PROTECTION
Asbestos Control Program
59.17 Junction Boulevard, B Floor. Corona, NY 11366-5107'
ONLY D.,.P ASBESTOS PROJECT NOTIFICATION
TYP
F t3E. (ASBESTOS INSPECTION REPORT)
.) ce!9'
• 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 17 J n
~.
OA A'L Borough _!3 Y Zip _ / 7
r 3. Block 4. Lot
5. Type of Facility 6. Name of Building
11. BUILDING OWNER 21'2.
7. Name _C.Ebt"-2- f~/~ Ev ,ST 8. Contact Person C ~~
9. Tel. #l?a- ~- Oi ax # .
~J J ~ ,~y~~'~-
10. Address 9-C V ~ -f s -r City Al _ State ~'"1Z10
Ill. GENERAL CONTRACTOR
11. Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name l B'~+l'. 1 ~'O 13. Contact Person / C2? --~- ' ,-
14. Federal Employer ID. # P11 15. Tel. # 16
' 7 'f -340 0 Fax #
. S
16. Address QJb f X2 ~ / ~ ,~
_City LJ /? t I State Zip II? ?'J
V. THIRD PARTYb"j(Al~ MONITOR
17. Name y R 11' -E2i► { a~t __ S+ rn C 18. Contact Person
19. Federal Employer ID. # 20. Tel. # ' 10 _-~ as - OO ? Fax # 2J3 " ~a -06 3 O
21. Address g 1, S L City C{'~ 1 '1 State j Zip 0O
22. Sample Analysis Laboratory Q04-r F« i^j A6s 7_A _f~s r _ 23. NYS DOH ELAP # (I -0
Vi. PROJECT INFORMATION
24.Starting date for this portion of work 6 / 13 / '
2 Projected completion date /
1 / g)
20
Asbestos work schedule 0 Monday ❑ Tuesday ❑ Wednesday 0 Thursday 0 Friday ❑ turday ❑ Sunday
Shift from: ❑ am ❑ pm to ❑ am 0 pm I/
If other,
specify RECNEB
Access to inspect the premises must be provided during the work schedule Indicated in this Item.
JUN 17 2002
DEP:3AfP4!'
25. Total amount of asbestos-containing material to be abated during this work ASBESTOS•' : j !!..
PR CGP%J.
Unear Feet /.J
0 Square Feet, and/or
ACP
x u° k Emt
4£LLSC°irkF J 3 frf:
RCQ
~ Pr~Gu"oRl. j'
NYC-WTC 000122776
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