NYC 9/11 Public Portal Document
'i j.a.±r na NYC DEPARTMENT OF ENVIRONMENTAL I
Asbestos Control Program
59-17 Junction Boulevard, 8°t Floor, Corona, NY I 1 B
ONLY FOR~OFFICIAL USE ONLY
vvv
ratil0~~
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 NYCOEP requires one copy of the form with original signatures. This
form must be submitted to the NYC DEP riot less than one week in advance of the start of abatement activities .
I. FACILITY
tt
2. Address —t 4 - CD C. tt
l't•10rM IW C S S j 12~ £ T Borough Q z_______
AKA 3. Block __. j_ ___ 4. Lot ?>
5. Type of Facility 6. Name of Building
11. BUILDING OWNER
9. Tel.# Fax#
10. Address ,Z, _ fo_ City N ' "f State r4 f o ©o-
III. GENERAL CONTRACTOR
11. Name Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name iI3?1l C.) ,CO 13. Contact Person " 73 t1&L/i
14. Federal Employer ID. # r P I I _ _ _ _ _ _ _.'15. Tel. # c~ - 7 i -3° ° 0 Fax # JI - ?d, 3c5
16. Address QL2 e City &t State Zip II? 9—
V. THIRD PARTY Al)i MONITOR
17. Name ___ Oj T~t~2-F12 J6 ~~ 18. Contact Person Ettc4 "L t..!oL kr4.
19. Federal Employer ID. # 20. Tel. # a (P - '?9 '- OO Fax # ,2Ja - UP - O6 -3 0
21. Address 2 e i 1 City I`i'GP 1~~ State Zip 00 t
EE7))
22. Sample Analysis Laboratory SC fE~t7( (G- h A6&7Z4i I£S1 7r' 23. NYS DOH ELAP # /I 8'C
Vt. PROJECT INFORMATION ,
24. Starting date for this portion of work 0 Projected completion date q n
Asbestos work schedule ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Friday ❑ Saturday ❑ Sunday
Shift from: ❑ am D pm to 0 am D pm ZW1 \
If other,
specify ' ~Iv 1.tJ
Access to Inspect the premises must be provided during the work schedule Indicated in this Item.
3:t AUG U_7 2UU2 1L) )
3
25. Total amount of asbestos-containing material to be abated during this work
Square Feet, and/or Linear Feet
.Z'7'J ti
kL'.::C tfiYiEu~~a'
~T
tong
NYC-WTC 000127201
OCR can misread numbers and units. Confirm readings against the page image before using them.