NYC 9/11 Public Portal Document
a
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IESI NY CORPORATION
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
11494 DATE
Owner's name Wait and Load
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5 laeektow Dept Of Enviro Protect +u3tne In
New boric, N \
Time Out
2. Drop Date
C9rs Ja t~ laS4r"3t3 . Son
' '4 Ralph Avenue
G roAlyn, NY I. U b
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R 3. wr s £I4 J I" andr31r tJldf3tion WDS phone number
A f' (;► Box 399
o Sc tland. Pa 17,53 Perm it 100934
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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 9, NA2212, III TYPE f / - Lam- l BAGS
SIZE I. ~' CUBICYARDS
a. Generator Certification ' +
.
T 9. ) ;,.'.' , ' <_ . _ 1': F' ,. '•. . I hereby declare that the contents of this consignment are fully and accurately 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 ,1/ r' u
S Pnnted/TypedName Title Si nattlfe Date
P 10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No.
O IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 1.1215 JA-462
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T / T~ DRIVER- . ' ,' ~ ' ~1:=~~G~•~-t .-- 7( r [ r t
E Printed./Typed Name Title •/ Signature cj Date M/D/Y) tI' 1
N1
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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Printed/Typed Name Title ` i nature Date (M/D/Y)
E 12. Discrepancy indication space 'C. ,
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T 3. Waste disposal site owner or operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
Printedrryped Name
I
Title
I ( ) / A/i
Signature
7/ /
Date (M/DLY')
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000119061
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