NYC 9/11 Public Portal Document
NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
Asbestos Control Program
59-17 Junction Boulevard. 81" Floor. Corona. NY 113685107 7 ii /5o/IAIo21
Building Dept. or TRU No
FOR OFFICIAL USE ONLv
ASBESTOS PROJECT NOTIFICATION
FORMS WILL BE (ASBESTOS INSPECTION REPORT)
ACCEPTED '1 '!"-~ (Sed1ee scfledule)
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 S ( .S 7 Q— Borough (' Zip________
AKA 3. Block 3 4. Lot I I-
5. Type of Facility 6. Name of Building
II. BUILDING OWNER
7. Name .a R-KS- ^0- L LL. 8. Contact Person
rcs&Q4Sv
9. Tel. k ~J ~h-- Fax #
10. Address E) l -Q-1 S I(2 -1- City 1~ State ft Zip I 00
III. GENERAL CONTRACTOR
11. Name TeI. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name 13. Contact Person s 9
14. Federal Employer /!f..._._._._._._._._. PI I X15. TeI. # J
- -(.3ao C Fax #_5Ifff &- 3d s•;5
10. "/ 7) r
16. Address 3O/(D ~l )O/?, t City _ '* u State Zip II? T~
V. THIRD PARTY AIR MONITOR
~j
&P kM Z.E2 l t r 5, ,f 18. Contact Person V (..(o (^ ftc 4
17. Name_(AJ P
19. Federal Employer ID. # 20. Tel. # f3 ' Fax# - P2 ' O 3 O
21. Address .I2Pg ~1ES1 . 1{ S ir2.fE7 City t fr ). uel '(~ State _ oo Zip
//
22. Sample Analysis Laboratory SG( 7(f!~- F f !1 S1 tc 23. NYS DOH ELAP # _(1 i1
VI. PROJECT INFORMATION
2
24.Starting date for this portion of work9 0L Projected completion date /J1 0 )-+
Asbestos work schedule 0 Monday ❑ Tuesday 0 Wednesday 0 Thursday 0 Friday 0 Saturday J Sunday
Shift from: 0 am 0 pm to ❑ am ❑ pm
K other.
specify
I Access to inspect the premises must be provided during the work schedule indicated in this item. I
25. Total amount of asbestos-containing material to be abated during this work
80 Square Feet, and/or Linear Feet
ACP 7
2/2001
fiJ!!*l r1 [
lit
f(Cin.JJ
NYC-WTC 000126237
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