Asbestos disposal and documentation form, undated

NYC 9/11 Public Portal Document

CT, MA, RI, VT, NH, ME E.P.A. AGENCY NY GENERATORS #99 48754 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, CT 06480 (860)347-0667 • Fax:(860) 342-4866 Boston, MA 02114-2023 (212)264-6770 TELEPHONE Out 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. CAROL LONG Address Address 3010 BURNS AVENUE 169 LIVINGSTON STREET city City WANTAGH State NY Zip 11793 BROOI~fN. NY 1120Rp (516)781000 Phone Number Telephone Number 06i262 07125Al2 Date Container Del. Date of Pickup GENERATING LOCATION Type of Container 100 YARD Address 25 WARREN STREET VOLUME 112 CY Friable Non-Friable ❑ city State Zi Bag X Drum ❑ Wrapped ❑ Other ❑ NEW YORK. NY 1000 Phone Number RQ, ASBESTOS, 9, NA2212, PG III INV * F1059 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/placarded, and are in all respects in proper condition for transport according to applicable international and national government regulations. AUTHORIZED SIGNATURE _ - MA Transporter 1: FIBER CONTROL INC_ SOiO BU NT06N NY 11769 549-79I~IYtn Address Telephone # Driver: _____ Registration #: NY 1480139 AR Date: 07124A)2 Signature State / # Acknowledgement of receipt of materials

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

Driver: Registration #: (~~l/ /P Date: Signature State / # Acknowledgement of receipt of materials.

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

Transporter 3: Name I 1.1 J Address Telephone # Driver: Registration #: Date: Signature State / # wledge t of receipt of materials.

Landfill Name: Phone No: Location: Approximate Volume of Asbestos Received: Discrepancy If Any: Qjr/.. Pem

Received by: Da Certification of receipt of materials covered by this manifest.

COPY 1 - GENERATOR NYC-WTC 000112770