NYC 9/11 Public Portal Document
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:oa '~''~~. Asbestos Cw ontrol Program
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TYPEWRITTEN ASBESTOS PROJECT NOTIFICATION
FORMS WILL BE TM~ (ASBESTOS INSPECTION REPORT) j,
=• R..~t ./~f~ (Seal
ACCEPTED
original form and three (3) copies with original
When submitting this form at the NYC Department of Buildings, the l
s res are uired. Submittal at the requires
signatures.s
be submitted to the NYC DEP not less Ethan In advance of the start abatement activitie
form must
1. FACILITY
Borough N ' 'i ZP
2. Address /07 1.3Rp4vLv A/
/ 3 Jj ( S %/ZE ( 3. Blocx (03 4. Lot 13
AKA
6. Name of Building
5. Type of Facility
II. BUILDING OWNER
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7. Name I)r -V i b W/,4
• • 8. Contact Person
9. Tel. # Fax #
10. Address 113 c , t20- city i 1 ` '1 state A zip (©o o'
Ill. GENERAL CONTRACTOR
Tel. #
11. Name_
IV. ASBESTOS ABATEMENT CONTRACTOR
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12. Name L F1 ~~ 1
20L 13. Contact Person /y 4
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P11 15. Tel
14. Federal Employer ID. # ._._._._._._._._._._._._._._._._._._._._._._; #-7~)1 -17 j'~ 3 0 a~ Fax #~ 6
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16. Address 3J a ji/R1~(S !4iL& _ city _1nJ !v t AC±f State .U.. zip
y LTHIRD.PARTY AIR MONITOR
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17. Name ~K2EN ( PAiJ
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K En R l nom + r 18. Contact Person r 4 , c
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`~20. Tel. ~)eJa') --0077 Fax #t91 '7~-~ _` t
19. Federal Employer ID. #
S~ city N ' `f State _ zip Do1
21. Address ._
22. Sample Analysis Laboratory$C/ e.-t.i if; C.
Agf~QA'02( L;/(23. NYS DON ELAP # 11
V1. PROJECT INFORMATION ©~
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24«Starting date for this portion of work_____________ Projected completion date _ii )
Wednesday ❑ Thursday ❑ Friday ❑ ❑ Sunday
Asbestos work schedule 0 Monday ❑ Tuesday 0
Shift from: ❑ am ❑ pm to ❑ am ❑ pm
If other. 4• `, '•
specify ElVFD
Access to Inspect the premises must be provided during the work schedule indicated in this
Item.
252002 ft l
25. Total amount of asbestos-containing material to be
Square Feet. and/or _
abated during this work
Linear Feet -
B
>4J)) ACP
.
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NYC-WTC 000123046
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