NYC 9/11 Public Portal Document
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I,ESI NY CORPORATION
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
1
11357 DATE
1. Job Site Address Owners name Wait and Load
88 Nassau Street Dept (3f Etvro Pt4ectio Time In
New York, N.Y. Time Out
2. tractors name 5410 add s Drop Date
.tf+ D a st !f1 3`akltZi7an & Son
1238 Ralph Avenue
E Broakly , NY 11236
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R 3. ( DRie tksn1ilL k, *p fl 6ation WDS phone number
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TT P.Q. Box 394 ""
O Scot.land, Pa. 17254 Permit 0100934
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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.
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Title
( ' Signature Date (M/D'1
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10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No.
O IESI NY CORPORATION • 110 5th Street, Brooklyn, NY lJ. 15 JA-462
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T 7' DRIVER ~ f/ G+...1..~ / ..r/ t,.
E Printed/Typed Name Title Si nature Date M/D/Y
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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Printed/iyped Name
12. Discrepancy indication space
Titl Si et DatE / ,Y
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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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Printed/Typed Name Title 'Signature Date (M/D
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000099261
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