15 JOHN STREET 1001217, 79/14

NYC 9/11 Public Portal Document

TESI NV- 0 2PORATION 110 5th Street • Brooklyn, NY 11215 Phone: 718-522-2263 • Fax: 718-522-2697 MANIFEST

1 1 . 765 DATE >1 1. Job Site Address Owner's name Wait and Load

15 ielm Stred. of Eo> >t+ Time In. New York,, N.Y. Time Out

2. Contractor's name and address Drop Date

Benjeaun Kurzben & Sen • I24aReJphAvaue N & tys, lam' 11236 E R 3. Waste disposal site (WDS) name, mailing address and physical site location WDS phone number, A T O IESI PaBlue RAdgeLa I Corpe* e R .O.E4X39 Scetlaud,Pa1fl54 PeaiI#IIOO934, 4. Name and address responsible agency (Local, District or EPA Office where notification was sent)

US EPA 290 Broadway, New York 10007

5. Description of materials 6.VEH. LIC. # 7. TOTAL QUANTITY (RQ) WASTE ASBESTOS 9, NA2212, III TYPE BAGS • . SIZE CUBIC YARDS g. Generator Certification

T 9. CONTRACTOR CERTIFICATION: I hereby declare that the contents of this consignment are fully and accutately described R above by proper shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition for by A highway according to applicable international government regulations. N S Printed/Typed Name Title Signature Date(M1D/Y) P Transporter #1 (Acknowledgement of receipt of materials) 10. DEC Permit No. R SI NY.CO RATION • 110 5th Street, Brooklyn,. 1 4 g fi~ (~r {~ DRIVER , •y++ ted/f Name. Title Si tore Date 11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT # W

S T Printed/Typed Name Title Si re Date F/

E 12. Discrepancy indication space

S

T 13. Waste disposl.site owner or operator: Certification of receipt of asbestos materials covered by this manifest, except as noted in item #12 E

tr ~y t 1: 1{b yir . . .~d ?~ Printed/Typed Name . Title Signature Date (M/D/Y)

WIIITE:LANDFILL • GREEN:IESI •PINK:GENERATOR.•YELLOW:CONTRACTOR -GOLD:JOB SITE

NYC-WTC 000094218