NYC 9/11 Public Portal Document
• IESI NYr RpORATION 1
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
DATE l~
Owners name Walt and Load
l • Job Site Address
164 Williem. 5 Of Eliviro Protection Tune In
New YoI , NY. Time Out
2 Coetraaorsname and address Drop Date
B.jamKanubea&Soa
O 12 Rih Avenue
E &*AIM NY 11236
N
E
R 3. pp¢ h sitar WD6 playa mm~ber
JD{!@17 Afi~
T P.O &opt 399
OR Seed"Pa 1'7x234 Pad 010Ql34
4. Name and address responsible agency (L.ocel. District or EPA Office whore notification was sag)
US EPA 290 Broadway, New York 10007
5. Description ofMate ials „w? £ 4 7. TOTAL QUANTITY
6.VEH. LIC. #
(RQ) WASTE ASBESTOS 9, NA2212, III TYPE BAGS
SIZE CUBICYARDS
8. Oamstarc tincation
2%J/y g
T 9. CONTRACTOR CERTIFICATION: I hereby declare that the contents of this consignment are fully and accately described
R above by proper shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition for Irpasport'by
A highway according to applicable international government regulations.
N
S Name Title Slasature Date
P 10. Transporter #1 (Mbowlat.sment of rxdpt of aieeaisls) D W442
I SI NY CORPORATION • 110 5th Street, Brooklyn, NY 1 21S JA-462
R
T e fIr#t DRIVER
E 'Two S1 Dace
LL
[
R
11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
W
T PdatWr Name rItIe Dste
E 12. Discrepancy indication space
S
I
1 13. Waste disposaj.site owner or operator. Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
E
Y \. jr s V1 C l
Pnnted/ryped Name Tile Signature Date (ht/DJY)
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000110923
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