NY State Dept of Labor Asbestos Notification Form, Oct 2001

NYC 9/11 Public Portal Document

ASBESTOS PROJECT NOTRCATON STATE OF NEWYORK 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 ................. Complete Section G and attach copy of initial notification or complete all sections.

EJ Emergency......,.... . You must first call the Program Manager's office of the Asbestos Control Bureau at 518-457-1255 for prior approval of emergency status, then complete and return this form including: Date ( / t' ) Time ( ) Emergency Status Granted Authorized by: (From Asbestos Control Bureau)

R. CONTRACTOR INFORMATION

Provide all information requested below. 1. FEIN [ PII 2, Asbestos Lic, No. 9 g - Q EII11IEIII18 3, Contractor Name and Address 4, Mailing Address (if different) Ha7ar(1ni is F minitinn Cnrp Same 195H Central Avenue Farmingdale, New York 11735

5, Duly Authorized Representative 6. Will Sub-Contractor(s) be used o ❑ es (ifyes, complete lines below) Name Donald Gold Name

Title Vice President Asbestos Lic. No. LIII -Lillill Phone No. ( 631) 752-2898 Name

7. Party for Whom Work is Being Performed: Name The Cooper Group, Inc. Address 666 Fifth Avenue, New York, NY 10103

C. PROJECT SITE INFORMATII

Provide all information requested below,lor the building/sue tit which the asbestos project will he conducted. 8. Project Location: County New York Name of building Room or other specific location Entire Basement, 1st and 2n floors, roof and facade Street address 23 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 Phone No. ( 1)2. 14 SH-483 (10-03)

NYC-WTC 000127816