NYC 9/11 Public Portal Document
E.P.A. AGENCY #99 4 9 O Q ci
CT, MA, RI, VT, NH, ME NY GENERATORS
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
Boston, MA 02114-2023 (212) 264-6770 TELEPHONE
(860)342-0667 • Fax:(860) 342-4866
Out of State 1-800-272-3867 (617) 918-1111 #1-800-272-3867
FB# ' j-nn, ASBESTOS DISPOSAL & DOCUMENTATION FORM
Job Number .0. # GENERATOR/BUILDING OWNER
Contractor FIBER CONTROL INC. 54 WARREN STREET LLC
3010 BURNS AVENUE Address 1385 WEST BROADWAY
Address
NY Zip 11793 City NEW SRK. NY 100AP
City WANTAGH State
(516)7813000 Phone Number
Telephone Number
Date Container Del. Date of Pickup GENERATING LOCATION
Type of Container 100 YARD Address 54 WARREN STREET
VOLUME 1116 CV Friable ~j Non-Friable ❑ City
NEW Y&W. NY 1001'
Bag Drum ❑ Wrapped Li Other ❑ Phone Number 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 5O P
Transporter 1: FIBER CONTROL INC. E WANTA9H. NY 11733 516-781-3000
Na e Address Telephone
Driver: Registration #: NY 1480139 AR Date:
Signature State / #
Acknowledgement of receipt of materials.
Transporter 2: Waste ManagemOrft .Df:E.E. 144. Portland. CT 06480 1-800-272-3867
Driver: istration #: (/ ~ l~~ Date:
State / #
Acknowledgement of receipt of materials.
TEMPORARY STORAGE / TRANSFER FACILITY: WASTE MANAGEMENT N.E.E.T., INC. • 203 PICKERING STREET • PORTLAND, CT 06481
a - _ -
PHONE: (800) 272-3867 PERMIT # SW 1130223
Received By:
Certification of receipt of materials covered by this manifest.
Transporter 3:
Name Address
Driver: #: Date:
State /#
of receipt of materials.
Landfill Name: No:
Location:
Approximate Volume of Asbestos Received:
Discrepancy If Any:
Received by: T 7-,2C -dZ.
Certification of receipt of materials covered by this manifest.
COPY 1 - 3ENEPATOR
NYC-WTC 000113174
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