NYC 9/11 Public Portal Document
IESI .NY CORPORATION
• 110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
11356 DATE
1. Job Site Address owners name Wait and Load
86 Naai St Dept Of EliVro Prdtecti Time In
Time Out
2. C ? 7 drd Drop Date
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1248 Ralph Avenue '`-
G iclyn, NY 11236
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R 3 ya 0pition WDS phone number
A
o 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 y .
5. Description of materials r
6.VEH. LIC. # 7. TOTAL QUANTITY
(RQ) WASTE ASBESTOS 9, NA2212, III TYPE "• ' ' BAGS
SIZE ,,.. CUBIC YARDS
8. Generator Certification
_______________ ________________
22
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 internatio overnment regulations.
S Printed/Typed Name Title Signature
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Date (
7 / /
•
P 10. Transporter #1 (Acknowledgement of receipt of miterials) DEC Permit No.
O IESI N).CORPORATION • 110 5th Street, Brooklyn, NY 11 15 JA-462
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T *.- DRIVER .G-a ^4 s' ~.+,►, _ r i.
E Printed/typed Name Title Si ature Date M!D/Y
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11. Transporter #2 (Acknowledgement of receipt of materials) EC PERMIT #
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Printed/Typed Name
12.
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Discrepancy indication space
Title Signaw Date /Y)
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1 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/IypedName
V q
Title
Cr i
dLA
azure Date(M/D/Y)
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000099313
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