202 BROADWAY 1001221, 79/19

NYC 9/11 Public Portal Document

Ea 24 WTIL y~y, WTY OB.{gl~ ryi NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION Asbestos Control Program S. 59-17 Junction Boulevard, 8°f Floor, Corona, NY 11368-5107 - Building Dept. cr TRU No FOR OFFICIAL USE ONLY ~pOjy"1eriraipao~c ASBESTOS PROJECT NOTIFICATION BE (ASBESTOS INSPECTION REPORT) PTEr7 www.nYc.portaer . .q

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 2Q2 13ROADLUAY -- Borough MAN Zip

AKA 3. Block ' 4. Lot 19

5. Type of Facility COMMEQGIAt_ _ 6. Name of Building II. BUILDING OWNER

7. Name • . 8. Contact Person

9. Tel. # _ _— Fax #

10. Address City State —__ Zip

Ill. GENERAL CONTRACTOR

11. Tel. #

IV. ASBESTOS ABATEMENT CONTRACTOR

12. Name ©611SAMIN .l{.t;_,.7-A.a.L~t._. _._5~N_._CC.N RcL._ _13. Contact Person _L";E t AwMleC _______ P 14. Federal Employer ID. #. l l ______ 15. Tel. # 1,118) 531- 2 9CO _____ Fax # _( t tBL7. C9=i 8 _____

16. Address L Z48 RALPH AViE N~1E ------ City 13?cOlc!Yw—_ —_ T _ State ...±L..Zip_J! _..

V. THIRD PARTY AIR MONITOR

17. Name Gti ~ PAM ER ENQ# __ ___18. Contact Person Mic"AE1... Me L.AN

19. Federal Employer ID. # 4 PII 20. Tel. # C 007'r _ Fax # (212 i 922^ 0630

21. Address _ 2 2 ~s 'E AS TA 1 TH 5 Tw-reT _____ City M N eW f cRV- NN___ State _N j_. Zip _ C c Q I T

22. Sample Analysis Laboratory—______ _ ----- 23. NYS DOH ELAP #

VI. PROJECT INFORMATION 24- Starting date for this portion of work ,L7lO Z' "t Projected compietion date J-1~-/2 ?--r Asbestos work schedule 21 Monday 0 Tuesday 0 Wednesday 0 Thursday 0 Friday 0 Saturday I Sunday

Shift from: ® am 0 pm to 0 am IN pm ti r -

if other, r ,pc/+~.

Access to inspect the premises must be provided during the work schedule indicated In this item. U ~► r) { 25. Total amount of asbestos-containing material to be abated during this work ti S r 14 SSO Square Feet, and/or O Linear Feet 2 ACP E 21200 •y • t a.aiiL

NYC-WTC 000123243