NYC 9/11 Public Portal Document
4
IESI NY CORPORATION
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
11242 DATE
1. Job Site Address Owner's name Wait and Load
118 Natsw Stred Dept Of Eaiiironm.en Time In
New K.Y. Protection
Yoek' Time Out
2. Drop Date
C V Ti i1it &
1248 Ralph Awe
G Brooklyn, NY 11236
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R 3. antion WDS phone number
A P_0. Box 399
0 Scotland, Pa 17254 Permit # 100934
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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
8. 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 transport by
A highway according to applicable international government regulations.
$ Pnnted/f Name Title Signature Date s '}
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10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No.
O IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 11215 JA-462
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E Printed/Typed ame Title - Signature TTCJ rate(M/DN1 + t<
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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A ^J
T PrintedtTypedName Title Si u ' Date M/D/Y
E 12. Discrepancy indication space
S
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T 13. Waste disposal site owner or operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
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rinted/fyped Name Title
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Signature
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Date (M/D/Y)
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000098784
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