NYC 9/11 Public Portal Document
IESI NY CORPORATION
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
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MANIFEST
11245 DATE
I • Job Site Address Owner's name Wait and Load
116 Nassau Stred Dept Of EnviXo ent Time In
New York, N.Y. Prate coon Time Out
2• Drop Date
' 90 I LilitZegan & 5on
1248 Ralph Avenue
c &oeklyn. NY 11236
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N
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R 3. slry @t t tp glj tion WDS phone number
A P.O. 39
o Sc tland, Pa.17234 Pam it # 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.
N
S
_______________
Printed/Typed Name
___________
Title Signature
/ 4
Date (M/D
7 /, /
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10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No.
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R IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 11215 JA-462
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T 7' X -` , ( /0 t
E Printedlfyped Name Title Si ` ature Date M/D/Y
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
T Printed/Typed Name Title Si na se Date(M/L)Y)
E 12. Discrepancy indication space
S
I
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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Printed Typed Name
Vt
Title
r('pr Signature
V L I ________________
Date (M/D/Y)
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000098892
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