EPA waste management generator form, EPA Region 2

NYC 9/11 Public Portal Document

1 CT, MA, RI, VT, NH, ME E.P.A. AGENCY NY GENERATORS #99 48753 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, Cr 06480 TELEPHONE (860)342-0667 • Fax:(860)342-4866 Boston, MA 02114-2023 (212) 264-6770 Out of State 1-800-272-3867 (617) 918-1111 #1-800-272-3867

FB# vR-j_'j(p ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number P.O. # GENERATOR/BUILDING OWNER Contractor FIBER CONTROL INC- STAR OF DAVID ASSOC 3010 BURNS AVENUE Address 111 IUM SII~ Address City City WANTAGH State NY Zip 11793 NEW YCT , t 10013 Zip l5' 781-3000 Phone Number Telephone Number Date Container Del. Date of Pickup GENERATING LOCATION

Type of Container 100 YARD Address 111READE STREET VOLUME ins CY Friable Non-Friable ❑ city NEW di K. NY IM Bag Drum ❑ Wrapped Lb Other ❑ Phone Number INV # F1059 RQ, ASBESTOS, 9, NA2212, PG III 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' all respects in proper condition for transport according to applicable international and national government regulations. AUTHORIZED SIGNATURE Transporter 1: FIBER CONTROI. INC. 3010 BU NIAGH. NY 11793 aareSs Driver: 1 U ___ Registration #: NY 1480 I39 AR Date: Signature State / # Acknowledgement of receipt of materials.

Transporter 2: Waste Mangmemsrit N.E.E.T., I

Driver: Registration #: c ~~1l, Date: I nature State / # Acknowledgement of receipt of materials.

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

Transporter 3: e Address Telephone # Driver: Registration #. Date: Signature State /# Acknowpdgement of receipt of materials.

Landfill Name: Phone No: Location: Permit Approximate Volume of Asbestos Discrepancy If Any: Received by: Certification of receipt of materials covered by this manifest.

COPY 1 - GENERATOR NYC-WTC 000114773