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 49003 WASTE MANAGEMENT GENERATORS EPA Region 2 LOGANO EPA New England 1 Congress Street 290 Broadway, 26th Floor EMERGENCY RESPONSE P.O. Box 144 - Portland, CT 06480 New York, NY 10007-1866 (860) 342-0667 - 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# (p ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number GENERATOR/BUILDING OWNER Contractor FIBER CONTROL INC. F PFEIFER CORP Address Address 3010BURNSAVENUE 53 WARREN STREET City City WANTAGH State NY Zip 11793 NEW `Y ~I(, NY 1001h' (516)781000 Phone Number Telephone Number 0626102 07125 Date Container Del. Date of Pickup GENERATING LOCATION Type of Container 100 YARD Address iWA N IKbl VOLUME 1116 CY Friable Non-Friable ❑ City Drum ❑ NEW , NY 1000 Bag Wrapped ❑ Other ❑ Phone Number RQ, ASBESTOS, 9, NA2212, PG III INV t 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 i all respects in proper condition for transport according to applicable international and national government regulations. AUTHORIZED SIGNATURE • Transporter 1: N e Driver: Registration #: NY 1420 139 AR Date: Signature State / # Acknowledgement of receipt of materials.

Transporter 2: Waste Mana em N.E.E.T. Inc. PO Box 144 Portland CT 06480 1-800-272-3867

Driver: Si nature Registration # O///# State/# Date: , 6)7) Acknowledgement of receipt of materials.

TEMPORARY STORAGE / TRANSFER FACILITY: WASTE MANAGEMENT N.E.E.T., INC. • 203 PICKERING,STREET • PORTLAND, CT 06480 c I .,.-. 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 / # Acknowle ement of receipt of materials.

Landfill Name: Phone No: Location: Approximate Volume of Asbestos Received: Discrepancy If Any: Received by: / ' k.L,X ,4A_/_i( r_ Certification of receipt of materials covered by this manifest.

COPY 1 - GENERATOR NYC-WTC 000113262