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Document / 6 pages

NY State Dept of Labor Asbestos Notification Form, Oct 2001

Machine-extracted title · confidence 95%

Initial asbestos notification form submitted to the New York State Department of Labor for a project at 133 Fulton Street.

NYC-WTC_000127813–000127818

Folder label: “BINDER - PHASE 1 DECONTAMINATION PLAN”

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NYC 9/11 Public Portal Document ASBESTOS PROJECT NOTIFICATION STATE OF NEW YORK Division of Safety & Health DEPARTMENT OF LABOR Asbestos Control Bureau Building 12, Room 157 State Campus Albany, NY 12240 A. TYPE OF NOTIFICATION _ Check only one type of notification below. Initial... . Complete all sections and submit 10 calendar days prior to starting date. Amended... Submit amended notification with all sections completed and amended item(s) circled. [| Cancelled ow. Complete Section G and attach copy of initial notification or complete all sections. [| Emergency «0 You must first call the Program Manager's office of the Asbestos Control Bureau at $18-457-1255 for prior approval of emergency status, then complete and return this form including: Date(__/ / sd) «Time ¢ ) Emergency Status Granted Authorized by: (From Asbestos Control Bureau) B. CONTRACTOR INFORMATION © Provide all information requested below. 1. FEIN Pil 2. Asbestos Lic.No. jg |g |-|Ol 14 |g 3. Contractor Name and Address 4, Mailing Address Uf different) Hazardous Elimination Corp Same 195H Central Avenue Farmingdale, New York 11735 &. Duly Authorized Representative 6. Will Sub-Contractor(s) be used [ha No [LIV es (f yes, complete lines below) Name Donald Gold Name Title Mice President Asbestos Lic. No. - Phone No. (631) _ 752-2898 Name Asbestos Lic. No. ~ 7. Party for Whom Work is Being Performed: Name Ihe Cooper Group, Inc. Address 666 Fifth Avenue, New York, NY 10103 C. PROJECT SITE INFORMATION Provide all information requested below for the building/site at which the asbestos project will be conducted. 8. Project Location: County New York Name of building Room or other specific location Entire Basement, 1st and 2nd floors, roof and B-2 facade Street address 133 Greenwich Street aka 25-29 Thames Street City, town or village New York, New York 10006 9. Building Information Current use Commercial Building age Prior Use Commercial Building size sq. ft. 10. Building Representative/Site Contact: Name Chanan Rozenbaum _phoneNo. ( 2 h2 208-4614 SH-483 (10-03) NYC-WTC_000127813

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NYC-WTC_000127813Source: NYC Law Department, mirrored locally

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