NYC 9/11 Public Portal Document
C .
I
IISI NY CORQ.I~ATION
1p 5Mi Street • .Brooklyn; NX 11215 /
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
DATE
1. Job Site Address owners name Wait and Load
116 Nasau S►treEt Dept of Ens*rottmental Time In
N Y New York, NY. Protection Time Out
2. CrAjWjbad adman & Drop Date
1248 Ralph Avenue
G Brooklyn, NY 11236
E
N
R 3• WDS phone number
A P.D. Box 3s
T • Scot}and, Pa. 172.54 Permit # 111493
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4. Name and address responsible agency (Local, District or EPA Office where notification was seta)
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 3 CUBICYARDS
8. Generator Certification
T 9. C NTRACTOR CERTIFICATION: I hereby declare that the contents of this consignment are fully and accutately described
R aboveby pvper shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition for transport by
A hi a 4cor n to plicable international government regulations.
N
S Printed/Typed Name Title Signature Date(
P
10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No.
O IESI NY CORPORATION • 110 5th Street, Brooklyn, NY I L 15 JA-462
R
E Printed/Typed Name Title /Signaure Date (M/D/Y)
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
W
A
r_
T
E
Printed/Typed Name
12. Discrepancy indication space
Title Signatu Date (M/D/Y)
S /
T 13. 'Waste disposal site owner or operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
E
t .
Prntedrryped Name Title Signature t Date (M/D
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000098893
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