Asbestos inspection form, 21 Ann Street, June 2002

NYC 9/11 Public Portal Document

0

. .IESI NY CORPORATION 110 5th Street • Brooklyn, NY 11215 Phone: 718-522-2263 • Fax: 718-522-2697 MANIFEST //j'

11246 DATE

1. Job Site Address Owner's name Wait and Load 21 Ann Street Of Envifoameetal Time In New York, N.Y. Protection Time Out

2. C rector's name add Drop Date isenj m t & Son 1248 Ralph Avenue E Brooklyn, NY 11236 N E R 3. F [ ~ahsiosl lion WDS phone number

T P.O. Box 399 o 'Seadend, Pa 172S4 Phi# # 1d09►34 R

4. Name and address responsible agency (Local, District or EPA Office where notification was sent)

US EPA 290 Broadway, New York 10007

5. Description of materials 6.VEH. LIC. # 7. TOTAL QUANTITY (RQ) WASTE ASBESTOS , NA2212, III TYPE ' BAGS SIZE CUBIC YARDS 8. Generator Certification

T 9. CONTRACTOR CERTIFICATION: I hereby declare that the contents of this consignment are fully and accutately described R above by proper shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition for transport by A highway according to applicable international government regulations. N S P Printed/Typed Name Title Signature Date M/D 7/ V r •tT iii Z

10. Transporter #1 (Acknowledgement of receipt of materials) DEC PeiII7it No. O IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 11- 15 JA-462 R T E Printedttyped Name fy ^BR Title '_ Signature pate M/D '7 /Q f 10 T 11. Transporter #2 (Acknowledgement of receipt of materials) 42 DEC PERMIT # W

S Printed/Typed Name Title Signatu Da /D T E 12. Discrepancy indication space

I T 13. Waste disposal site owner or operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12

yPrint yped Name ______

Title _________

Signature _________

Date (M/DfY) rr

WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE

NYC-WTC 000116478