NYC 9/11 Public Portal Document
~~ qrr ouM~y NYC DEPA1(TMENI OP ENVIRONMENTAL
PROTECTION
Asbestos Control Program n
1
1 EWRITTEN
o
59.17 ,Iwctlpn Bouhv~, 8ei Floor, Comm.
orona, NY 119Q8.S/07
ASBESTOS PROJECT NOTIFICATION o►Ta~n
FOR ,Ow MI MI
.c- FORMS WILL 8E
ACC Preo
~s110
(ASBESTOS INSPECTION REPORT) 1
When submitting this form at Me NYC
Department d Buildings, the original form end three (3) copies with
signatures are required. Submittal at the NYCDEP requires orfgi
form must be submitted to the NYC DEP one copy of the form with original signaturss. T
not Iwe than one week In advance of Si. start of
abatement actMMties .
I. FACILITY
2. Address JiO^~
Borough Zip
3. Block 4.Lot
5. Type of Facility _
._ _ 6. Name of Building
It. BUILDING OWNER
7. Name
8. Contact Person
9. Tel.# —
— Fax >C
10. Address _ _ +_-----~ City,
Ill. GENERAL CONTRACTOR
11. Name_
----"~-- -------- ------ —~_ Tel. #
IV, ASBESTOS ABATEMENT
CONTRACTOR
12. Name
-f —~-~e ------------- __13. Contact Person
14. Federal Employer ID.
Tel. tc
f 7 I 300
- 0 Fax
16. Address
V. THIRD PARTY AIjt MONITOR
---- City_AJIZJ LL3EL State Zip 1L22
l/
17. Name t rtt~(y ~tZ tt(t
C__18. Contact Person J 4 1. (0LkrJ.
19. Federal Employer ID. #
_ 20. Tel. # a ~e~ -O — Fax
21. Address ~-C itST~ ,, zc
City -~~----~ State £41.Zip L2L
22. Sample Analysis Laboratory ~f t? / lL kje7Atfe7e/e$ ~c
23. NYS DOH El.AP rtl _LL
VI. PROJECT INFORMATION
24. Starting date for this portion of
work _ _~ __O -
Projected completion h
date
Asbestos work schedule ❑ Monday d Tuesday ❑ Wednesday
0 Thursday © Friday d Sat
nday
Shift from: _ — ❑ am ❑ pm to
❑ am ❑ pm
If other,
RE~vEO
1iI Aecess to inspect the premis.s must be provrded dwfng
the Wdm schedule lr►dVesfer! In this Item N JUN 2 8 2002 of
25. Total amount of asbestos-containing
material to be abated during this work
j ROGRAMh'i
- quafe Feet, and/or Linear Feet TRUG
1 2
o~T
H.«f;CutrY S L•if.: rT+tt 1
+
l~nFN4 1Ml _ 212001
OT'd L?: TT ZOOL 8Z unC c2VT-T92-ZTZ:Xed K-13 d30
NYC-WTC 000126289
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