NYC 9/11 Public Portal Document
IESI NY CORPORATION
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
11360 DATE
I. Job Site Address Owner's name Wait and Load
5 Beekman Stneet Dept Of Eavlro P*edi rrime In
New York, N.Y. Time Out
2. C tractor s name a~ a_dd s Drop Date
B!'tl~~ii iii n3i.12fV & ~J(!~
t
1248 Ralph Avenue
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E
Brooklyn, NY 11236
N
E
R 3. ai IM tion WDS phone number
AT P.O. &'x 399
O Scotland, Pa 17254 Permi 0100934
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1
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
V 6.VEH. LIC. # 7. TOTAL QUANTITY
(RQ) WASTE ASBESTOS 9, NA2212, III TYPE ' BAGS
SIZE CUBICYARDS
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 internationa vernment regulations. >
NS
Pnnted/T edName Title
(-
Signature
L o v l ._ Date (M
10. Transporter #1 (Acknowlsdaement of receipt of materials) I DEC Permit No.
O
R IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 1 15 JA-462
T 4., DRIVER 7 / / '/
E Printedrfyped ame Title 4ign re TT T Date M/D/Y
R
II. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
W
S Printed/Typed Name Title Signature Date M/D/Y
T
E 12. Discrepancy indication space
S
T 13. Waste disposal site owner or operator; Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
E
K .~,edl~~Name Title Signature
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
Date (M/DIY)
NYC-WTC 000119059
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