11 JOHN STREET

NYC 9/11 Public Portal Document

ISI N3 RPORATION ~ 110 5th Street 0' Brooklyn, NY 11215 Phone: 718-522-2263 • Fax: 718-522-2697 MANIFEST

1• Job Site Address DATE 7/ '/' «".

1 ame 1I Wait and Load rD; Time In N.Y. Time Out ti 1 2. Contractor's name and address Drop Date G 12 11 N•. 11236 E R 3. Waste disposal site (WDS) name, mailing address and physical site location A number

Se,thn4 17254 4. Name and address responsible agency (L;odal, 100934 District or EPA Office where notification was sent) US EPA 290 Broadway, New York 10007

5. Description of materials

(RQ) WASTE ASBESTOS 9, NA2212, III 6.VEH. LIC. # TYPE ' 244 7.. TOTAL QUANTITY

BA SIZE 8. Generator Certification CUBICYAR Li a T 9. CONTRACTOR CERTIFICATION: I hereby R _. above by proper shipping name and are classified, declare that tie contents of this consignment are fully and accurately described

i packed, marl ed and labeled, and are in all respects A highway according to applicable internationalgovernment in proper condition for by regulations. N ,/r•# mss,, S Printed%I Name v 4 P Tale Signature Date 10. Transporter #1 (Actatowledgement.of receptof materials) O IE NY CORPO TION • 1I 0 5th Street, Brooklyn, NY. DEC Permit No. T DRIVER Pn tedlf a R ide 11. Transporter #2 (Acknowledgement.of receipt of materials) W DEC PERMIT # A .I,

E Printccvr 12. Name Discrepancy indicationspace Tide — shcIc Date M/D

S

T 13. Waste dispose site owner ac operator: Certification of receipt of asbestos materials covered E. by this manifest except as -noted in item #12 ' .

.d Printed/TypedName S Tide Signature , Date(M/D/Y) WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOWrni rru e rrnn • r,.,r T..,, 4'•:

NYC-WTC 000094127