Asbestos disposal manifest form, EPA Region 2

NYC 9/11 Public Portal Document

CT, MA, RI, VT, NH, ME E.P.A. AGENCY NY GENERATORS #99 49013 WASTE MANAGEMENT GENERATORS EPA Region 2 LOGANO EPA New England 1 Congress Street 290 Broadway, 26th Floor New York, NY 10007-1866 EMERGENCY RESPONSE P.O. Box 144 • Portland, Cr 06480 TELEPHONE (860) 342-0667 • Fax: (860) 342-4866 Boston, MA 02114-2023 (212) 264-6770 Oht of State 1-800-272-3867 (617) 918-1111 #1-800-272-3867

FB# ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number GENERATOR/BUILDING OWNER Contractor FIBER CONTROL INC. 53 MURRAY LLC 3010 BURNS AVENUE Address 53 MURRAY STREET Address WANTAGH NY Zip 11793 city NEW d? tc. NY 1000 City State (316)781 80 Phone Number Telephone Number Date of Pickup GENERATING LOCATION Date Container Del. Type of Container 100 YARD Address NURRAY STREET VOLUME 1116 CY Friable% Non-Friable ❑ City NEW NY 1001 BagX Drum p Wrapped ❑ Other ❑ Phone Number INv t F1059 RQ, ASBESTOS, 9, NA2212, PG III I certify the above named material does not contain free liquid as defined by 40 CFR part 260.10 or any applicable state law, is not a hazardous waste as defined,by 40 CFR part 261 or any applicable state law, has been properly described, classified and packaged, and is in proper condition for transportation according to NESHAP standards for asbestos waste disposal found in 40 CFR part 61.150. Shipper's Certification: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placii and alle.i aspects in proper condition for transport according to applicable international and national government regulations. AUTHORIZED SIGNATURE Transporter 1: I9 3ER CONTROL. INC. 4 BURNS AVENUEWAIWtAGI1. NY 117M3 518-781-3000 Name Address Tele one # Driver: Registration #: NY 1480 139 AR Date: 24102 Signature State! # Acknowledgement of receipt of materials.

Transporter 2: Waste Man a nt N.E.E.T., Inc. PO Box 144, Portland, CT 06480 1-800-272-3867

Driver. Registration # SO~// #-e Date: ignature State / # Acknowledgement of receipt of materials.

TEMPORARY STORAGE / TRANSFER FACILITY: WASTE MANAGEMENT N.E.E.T., INC. • 203 PICKERING STREET • PORTLAND, CT 06480 PHONE: (800) 272-3867 PERMIT # SW 1130223 Received By: Date: Certification of receipt of materials covered by this manifest.

Transporter 3: Name Address Telephone # Driver. Registration #: Date: Signature State I # Acknowledgement of receipt of materials.

Landfill Name:4 Phone No: Location: Permit Approximate Volume of Asbestos Received: Discrepancy If Any: Received by: Date: 72C' 6' Certification of receipt of materials covered by this manifest.

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