NYC 9/11 Public Portal Document
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? . Asbestos Control Program
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ASBESTOS PROJECT OTI ICATION _
TYPEWRITTEN
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FORMS WILL BE (ASBESTOS INSPECTION REPORT; 1. Lb1
ACCEPTED (See tee scti ule)
When submitting this form at the NYC Department of Buildings, the onginal 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.
FACILITY
2. Address R zD AP u . _ _ _Borough _±L ` Zip
AKA D S % I __ 3. Block (o d. Lot f
5. Type of Facility____ 6. Name of Building
II. BUILDING OWNER
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7. Name V, &4 , GU/r'J _ 8. Contact Person _w_
9. Tel. # Fax #
10, Address ~^ 6" Stets L Zip
III. GENERAL CONTRACTOR
11. Name Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name E1~-1zW~ 12 t " .. .M,..._~_ 13. Contact Person _____
14. Federal Employer ID. # P11 15, Tel. # : -
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16 gd&e5s > vA_1J E... - __ City •, AI StateiiLZlpIL 3 .
V. THIRD PARTY AIR MONITOR
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17. Name I ► ! trlv l ii S I c 18. Contact Person l C_
19. Federal Employer ID. # 20. Tel. (' d Fax
21. Address ~_ City /N State _-±_ Zip
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22. Sample Analysis Laboratory=S.~% err f t '"r G -F.rrE`t',L}I2fi fD/c~(L~ L nf' ^
X23. NYS DOH ELAP # ~r t
VI. PROJECT INFORMATION
24. Starting date for this portion of work t ~-) ~~-- Projected completion date _..,
Asbestos work schedule 0 Monday ® Tuesday 0 Wednesday ❑ Thursday 0 Friday 0 Saturday 0 Sunday
Shift from. _ am pm to D am pm
If other,
Access to inspect the premises must be provided during the work schedule indicated fn this item.
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25. Total amount of asbestos-containing material to be abated during this work
J 0 Square Feet, and/or Linear Feet
B ACR
~, a V200
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NYC-WTC 000123062
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