NYC 9/11 Public Portal Document
`1c (A) NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
,Q Asbastot Control Program
4 59-17 Junction Boulevard. 8" Floor, Corona, NY 11368-5107
D A P
ASBESTOS PROJECT NOTIFICATION
Building Dept. or TRU No
FOR OFFICIAL USE ONLY
çf rEN
WALMOnc
!LL BE (ASBESTOS INSPECTION REPORT)
EPTEO fee schedule)
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.
I. FACILITY
11 tt ~ -- S
2. Address _ I C t-thi 'Y~1~ ~I' nn
1~ `L 1 Borough _ — Zip_______
AKA 3. Block 4. Lot 32-
5. Type of Facility--__—_ 6. Name of Building
1I. BUILDING OWNER
A `!
7. Name N Ct (O M V- 1 b t Y L CJ0' 8. Contact Person
9. Tel. # y to W -`" 0 Fax #
10. Address 11 C—L "~ ~C S ~~_ City --- _ State _'iZip I oo7-
Ill. GENERAL CONTRACTOR
11. Name____. .... --- Tel. # — ---~
IV. ASBESTOS ABATEMENT~C~O.N,TRTACTOR
12. Name 1?t -----------------------
~"Z~---------__13. Contact Person ~L_____
14. Federal Employer ID. # P11 ) 5. Tel. # ~6 _
--1—'7L'~00L3
~— _-- __---
,1
16. Address 2t ~ — J --- City / / ~ State N Zip .iL _
V. THIRD PARTYIAlj~ MONITOR
r
17. Name 1r` V ; ~ ~► (Z a 46 i ~1 S r C 18. Contact Person ~ CI 4+ fL '`
19. Federal Employer ID. # ___---_~— O0:
20. Tel. # a ~ _1aa - ::_ Fax # 1a - a -0
21. Address ~~ L City ~ State ti_ Zip (00 ( .
--
22. Sample Analysis Laboratory— S~If 11~lL~^ c rwle5 " c 23. NYS DOH ELAP # - 1(
VI. PROJECT INFORMATION _
01 Projected completion date 02.
24.. Starting date for this portion of work _ _
Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday 0 Thursday 0 Friday ❑ Saturday ❑ Sunday
Shift from: ❑ am ❑ pm to ❑ am ❑ pm
If other.
specify ----------- — — rr
Access to inspect the premises must be provided during the work schedule indicated in this item. JUN Q
2
25. Total amount of asbestos-containing material to be abated during this work
°RD0E
G
Square Feet. and/or_________ Linear Feet
a ACP
6 2!200'
J!P
AI r
4Ed::C':R2Y 3
E'f.•.^~%tA7
rro ,
NYC-WTC 000127124
OCR can misread numbers and units. Confirm readings against the page image before using them.