NYC 9/11 Public Portal Document
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NYC DEPARTMENT OF ENVIRONMENTAL PROTECTION
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Mrq~Q Asbestos Control Program
59-17 Junction 13otdevard,.8~" Floor. Corolla. NY 11368-5107 1Q1flP'
Buibirg Dept. or MU No
' FOR OFFICIAL USE ONIV
PEWR17TEN " ASBESTOS PROJECT NOTIFICATION
FORMS WILL BE """'"`"tO (ASBESTOS INSPECTION REPORT)
ACCEPTED !"• jovret~ • ~•
( fee schedule)
When submitting this torm 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 act ties .
1. FACILITY
2. Address 119 C
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4#w 9T rtE
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T Borough ~_
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Zip 000
AKA 3. Block I 'T 4. Lot _ ___
5. Type of Facility 6. Name of Building
II. BUILDING ~OWNER
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7. Name 1 f ke „1 X ~•AS•~-7~ ~`-~' K- ` ` 8. Contact Person
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9. Tel.#t~` 3 2 - ~S4 (G Fax#
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10. Address _ , (
~--p -6 , t City States ip
111. GENERAL CONTRACTOR
11. Name" Tel. #
IV. ASBESTOS ABATEMENT CONTRACTOR
12. Name L3E' ( ! ,CO( 13. Contact Person 7 .)y'
14. Federal Employer ID. # P 15. Tel. # J 1 7
16. Address 0 d')O~ e City J &J ~7~ State L Zip
V. THIRD PARTY AI MONITOR
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17. Name b O~ +t K _Z 5 tZ 6 t'4 l rt~C 18. Contact Person MI L t( r
19. Federal Employer ID. # 20. Tel. # a -00 ' Fax # 2I1 _ 9-06.3 O
21. Address 2P 2EE7 City I`lw Te121~ State t'-( 1"_ Zip (00 j
22. Sample Analysis Laboratory_ . (i i' - .'466____c 23. NYS DOH ELAP # I t' __ -
VI. PROJECT INFORMATION
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24.. Starting date for this portion of work t1 2 0 Z. Projected completion date C) Z
Asbestos work schedule 0 Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Friday ❑ Saturda ''unday
Shift from: ❑ am ❑ pm to ❑ am ❑ pm
If other,
specify _~ Rip
Access to inspect the premises must be provided during the work schedule indicated in this item. JUN 2
8 2002 Ol
25. Total ammount of asbestos-containing material to be abated during this work rT 4lME:
alt
_.9I Square Feet, and/or Linear Feet O 2
6 ACP 7
8•JnFAti fir EP9P0'J mg 2/2001
KCCRAl.1
IR117
NYC-WTC 000127342
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