NYC 9/11 Public Portal Document
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IESI NY CORPORATION
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
11495 DATE 7 (277"~~-
L J,;h Site Address Owner's name Wait and Load
8iar' 1w,-Ia9t1 3S,~1':ird Dept Of EnvirO Prc,te . me In
N air Yo,•= c, .A'r- t.
Time Out
2. c Cx Drop Date
c3 t 3a #t & fl
E24 9 Ralph Avenue
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R 3. W pb tin !' ae i i t4 cation WDS phone number
A F0. Box 399
T Kr+C41thutLt. Pa. °.5.1 Petniit
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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 JL>>',- ~. CUBIC YARDS
g. Generator Certification
T 9. C ON T RA CTOR C E R T I F [CAT I O'. 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 i .. 11t Z y I I" c. 2
S Printed/Typed Name Title Si nature Date (M/Dl~r a
P 10. Transporter #1 (Aaknowledgemeet of receipt of materials) Permit No.
O IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 11215 JA-462
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E Printed/fyped Name Title ' Signature Date M/D/Y 1
1ST
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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Printed/Typed Name Title `gi ature Date(M/DN)
E 12. Discrepancy indication space
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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
Printed/Typed Name
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Title
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Sigtiafure"
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Date (M/D/Y)
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000099327
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