NYC 9/11 Public Portal Document
NYDEC 1A-371
37
NYDCA 483056
C,Q4bustoes d c/'~/`Arlalnsportation po., Inc.
P.O. BOX 1044 TOLL FREE PHONE 631-924-5050
HAMPTON BAYS, N.Y. 11946 1-800-755-OATC FAX 631-924-5085
"EMERGENCY NUMBER"
WaJe Manifest # Job # Floor or Location Cust #
4r~ G
1. Work Site Name and Mailing Address Owner's Name, Address, Phone Number
:'RIDE`..- FOOD STORES _INC.
nn
.j9 NASSAU 3 • `T .,9
[
NASSAU
A U C .• •
NEW YORK, .:. N.Y. • N.Y.
Contractor's Name, Address Waste Disposal Site
,, .st£_LM F.LL LANDFILL
R1 =?. BOX 68
i4 - 20 .219?: STREET
BRIDGEPORT. WV. 763: D
COLLEGE POINT. NY
Name and Address of Responsible NESHAPS Agency Other 0
U.S. EPA REGION II, 290 BROADWAY, NEW YORK, NY 10007
Description of Materials Bags - Cubic Y .
RQ Waste Asbestos, Class 9, NA2212, PGIII 0 Other
Drums or Tons - OTHER -
❑ RQ Waste White Asbestos, Class 9, UN2590, PGIII
Special Handling Instructions and Additional Information
OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper
shipping name and are classified, packed, marked and labeled and are in all respects In proper condition for transport by highway according to
applicable International government regulations.
________
Printed/Typed Name Title
x 4nature 4-n' - - 7/t
Date (M D/Y )
Transporter 1 (Acknowledgement of Receipt of Materials)
Company Name and Address Telephone No.
ASBESTOS TRANSPORTATION CO., INC. Signature: 631-924-5050
P.O. BOX 1044 Printed Name: Date
HAMPTON BAYS, NY 11946
Title: DRI R !iq
Transporter 2 (Acknowledgement of Receipt of Materials)
Company Name and Address Telephone No.
ASBESTOS TRANSPORTATION CO., INC. 631-924-O50
P.O. BOX 1044 Printed Name:j. D
HAMPTON BAYS, NY 11946
Title: DRIVER aG Q
Discrepancy Indication Space:
Waste Disposal Site Owner or Operator's Certification (Receipt of Above Waste Accepted)
ME ADOWF I L L LANDFILL Telephone No.
Signature:
1 , 304) S4-'-2' J4
Printed Name: Date
'"'~
Company Name and Address Title: "s ! Z t Q
NYC-WTC 000099768
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