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
owners name Wait and Load
1. Job Site Address
88 Nassau Street Dept Of Etwro Pt4ectio Time In
A1ew York, N.Y. Time Out
2. tractors name a.pi adds Drop Date
Is itJc'ttst!fl tal'l "zoi ~i & Son
124g Ralph Avenue
E Brooklyn, NY 11236
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E
R 3• s- In tion WDS phone number
4Wp8br
TT P.O. Box 399
O Scotland, 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
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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 Name Title
Ac'— Signature
1 Imo_
Date (M/D
(
r 9
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10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No.
O IESI NY CORPORATION • 110 5th Street, Brooklyn, NY l 15 JA-462
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T /
U — DRIVER f' 1 f7
E Printed/Typed Name Title Si nature
jjy Date M/D/Y
R 11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
W
T
E
Printedliyped Name
12. Discrepancy indication space
Titl Si at DatE 1 /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
E
Pnnted/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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