NYC 9/11 Public Portal Document
/it'f kJ-f --a t1ttUCIU ►OF ENVIRONMENTAL PROTECTION
l l pr,4t DEPARTMENT
.~'0 "'WM Asbestos Control Program
A r■~ 59-17 Junction Boulevard, 8"' Floor, Corona. NY 11368-5107 L 4?0%AM d
ONLY
TYPEWRITTEN
D ASBESTOS PROJECT NOTIFICATION
Nr ncc°̀~
Building Dept. or TRU No
FOR OFFICIAL USE ONLY
FORMS WILL BE (ASBESTOS INSPECTION REPORT)
ACCEPTED ..^" !.!' . ,
(See fee
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 _] ?r T — 1 Borough —J[_ Zip _ --~_
AKA ` `'l L~CJ;L— ` ~ _ 3. Block r 4. Lot
5. Type of Facility. 6. Name of Building
II. BUILDING OWNER
7. Name 1 L~CI✓ C (Dsi C' S G 8. Contact Person
9. Tel. Fax # _--_ --- ----
10. Address -__ __' City — r vv `( r±.
--- State J'1 Zip ---- -
Ill. GENERAL CONTRACTOR
11. Name_ Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name L .3 .€' l .YJ t ,OJ --------- _13. Contact Person _ __ '. L1.. _-
14. Federal Employer ID. # P 11 ' 15. Tel. # 616 - 7>~if -306 o 5/_ 7 3cg
Fax # _---------------
16. Address _30/( >1 C~ ?, i~_-- __- -- City —___ I/ l_--_ State .&_I Zip _LL22 _
V. THIRD PARTY AIR MONITOR
17. Name 1~v
11 ~ Z pNG i-f '~ S fC-18. Contact Person _
t
l!~+
r
t—►'``'
-----
19. Federal Employer ID. # --II ; 20. Tel. # Q 13 . - 0 Q . — Fax
21. Address .~~g city zip (
L—~ — ~t L--/-- `~w E7?~C----- State f- -L-
22. Sample Analysis Laboratory—_~~ (fl`<</ «- G_*6 0 r- °?'1t5 1( ` — 23. NYS DOH EJ AP #
VI. PROJECT INFORMATION
24.. Starting date for this portion of work Z Projected completion date
Asbestos work schedule 0 Monday ❑ Tuesday ❑ Wednesday 0 Thursday 0 Friday ❑ Saturday Sunday
0
Shift from: ❑ am ❑ pm to _--__ ❑ am ❑ pm `I • ` - -! ! ;~ '.
If other, cam '~ rO
P _-- RLCEIVC
L
Access to inspect the premises must be provided during the work schedule indicated in this item. JV N 1
1 2902 )11EE
25. Total amount of asbestos-containing l to abated this work _? ti
$frft
::1 rd;:
Square Feet• and/or '
212001
T
NYC-WTC 000126498
OCR can misread numbers and units. Confirm readings against the page image before using them.