NYC 9/11 Public Portal Document
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NYDEC 1A-371 NYDCA 483056
CQbeLo QanpoLaLion ., Inc.
P.O. BOX 1044 TOLL FREE PHONE 631-924-5050
HAMPTON BAYS, N.Y. 11946 1-800-755-OATC FAX 631-924-5085
"EMERGENCY NUMBER"
Waste Manife t # Ijob # Floor or Location I Cust #
1. Work Site Name and Mailing Address Owner's Name, Address, Phone Number
.ON`: SPV LAS ENTERPRISES
i r. 11 RTCTO ST.
VL r, . , - YEW YORK. YYk
Contractor's Name, Address Waste Disposal Site
IIEADr , _' i L T D .. _.
s., 41 .l ^^ 1
• OX a
1--2O 12 NTH STREET 3t 1JG~PORT. WV. 2P3. rt
_LEEF P0 IYT.
Name and Address of Responsible NESHAPS Agency Other ❑
U.S. EPA REGION II, 290 BROADWAY, NEW YORK, NY 10007
Description of Materials Bags - Cubic Y s. -
RQ Waste Asbestos, Class 9, NA2212, PGIII ❑ Other
Drums or Tons -OTHER -
❑ RQ Waste White Asbestos, Class 9, UN2590, PGIII —~'
Special Handling Instructions and Additional Information
OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper
shipping name and are classified, packed, marked and labeled and are in all respects In proper condition for transport by highway according to
applicable international government regulations.
_W Fc®
Printed/Typed Name Title
A(e I-ys 1, x Sig a Date (M/DD/YY)
Transporter 1 (Acknowledgement of Receipt of Materials)
Company Name and Address Telephone No.
Signature:
ASBESTOS TRANSPORTATION CO., INC. 631-924-5050
P.O. BOX 1044 Printed Name: 4 tLv Date
HAMPTON BAYS, NY 11946
Title: DRIVER
Transporter 2 (Acknowledgement of Receipt of Materials)
Company Name and Address Telephone No.
Signature: •✓
ASBESTOS TRANSPORTATION CO., INC. 631-924-5050
P.O. BOX 1044 Printed Name: ~/~J (, 9 J 7 Date
HAMPTON BAYS, NY 11946
Title: DRIVER
Discrepancy Indication Space:
Waste Disposal Site Operator's Certification (Receipt of Above Waste Accepted)
T ... :11\
Telephone No.
00W=• - I'' ' Signature:
Printed Name: Date
Company Name and Address Title:
NYC-WTC 000113846
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