NYC 9/11 Public Portal Document
NY CORPORATION >1
110 9th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
11494 DATE 7 / -e z A `a-
1. Job Site Address Owner's name Wait and Load
5 Eeekm at't tt a Dept Of Enviro Protect c»lrte in ''..
New York, N. Y Time Out
2. Ce rs Drop Date
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1248 Ralph Avenue
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R ' ItllI U tion WDS phone number
A P G Ex 499
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O Sccfitt cl, Pa.. 17'. l Penn it* 100934
4. Name and address responsible agency (Local, District or EPA Office where notification was sent)
VS EPA 290 Broadway, New York 10007
S. Description of materials 6.VEH, LIC. # 7. TOTAL QUANTITY
(RQ) WASTE ASBESTOS 9, NA2212, III TYPE (> 1,) ' BAGS
SIZE ., 1. CUBICYARDS
g. Generator Certification r'
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T 9. C `t'O T O R C E RT I F I C . T i i J';: I hereby declare that the contents of this consignment are fully and accutately described
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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.
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S Printedltyped Name Title Signat Date
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10. Transporter #1 (Acknowledgement of receipt of mateials) DEC Permit No.
IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 11,215 JA-462
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T 'DRIVER f w'`, ~t t °' t - 7lr r
E »` Signature Date M/D/Y 1
nt YPed ame Title 1T T
R 11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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S Printed/Typed Name Title \ —1gnature Date M/D/fl
F 12. Discrepancy indication space
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3. Waste disposal site owner or operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
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Printed/Typed Name Title Signature Date(M/DC.')
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000119110
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