NYC 9/11 Public Portal Document
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NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
Asbestos Control
w Program /'
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~ 59-17 Junction Boulvard. a I ioor, Corona, NY OY(
or TRu No
onicY •D ~~. FOR OFFICIAl. USE ONLY
ASBESTOS PROJECT NOTIFICATION
(ASBESTOS INSPECTION REPORT) 1.
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 I 4O C 4`14y 4I £Sb s tt T Borough N • Zip_ d -g0
AKA 3. Block 4. Lot
5. Type of Facility 6. Name of Building
1t. BUILDING OWNER
7. Name (t Ad- iC KA-C t A"M~• ' 8. Contact Person
9. Tel. # Fax #
10. Address _1 1/ 1,6 ~~ - City ( State Zip f ©Qo
Ill. GENERAL CONTRACTOR
11. Name Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name ee_ C d.~._._._._._._._. 13. Contact Person / ~'- )fc..
7t /'3 0
14. Federal Employer 1D. #j P!!_._._._._._._._.75. Tel. # cJ` l Fax # 5I ?di ' J S
16. Address 2QL2 1 __ t' City r State Mt Zip1f? 3
V. THIRD PARTY MONITOR
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17. Name____j R&J SZEt2. PC 18. Contact Person t O(" 4 .
19. Federal Employer 1D. # 20. Tei. # ' fa ' ga~o~ - D0 Fax # a - ~ - 06 O
21. Address Q2 g L_ '` S' E City 7'7 2 State j Zip 0 tf.
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22. Sample Analysis Laboratory S~tf1 71~lG- 4 23. NYS DOH ELAP # (f (.9
M. PROJECT INFDRMATION ,
24. Starting date for this portion of work O Projected completion date t) .----
Asbestos work schedule 0 Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Friday ❑ Saturday ❑ Sunday
Shift from: ❑ am ❑ pm to ❑ am ❑ pm
10
if other, 0
specify ttE NW a
Access to Inspect the premises must be provided during the work schedule indicated in this item. AUG 0,7
( 2002
25. Total amount of asbestos-containing material to be abated during this work
Square Feet, and/or Linear Feet 'l,
1' / t
4'.JefA~i E~ 7PP.?'x~{pr
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NYC-WTC 000127199
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