NYC 9/11 Public Portal Document
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SI NY CORPORATION
110 5th Street * Brooklyn, NY 11215 }
Phone: 718-522-2263 * Fax: 718-522-2697
MANIFEST
11494 , f DATE_________
t. Job Site Address Owners name Wait and Load
5 Deekm eai Stted Dept Of F. avir'o .Er'+ tat fi ne In ,•
New Yo k, NY. Time Out
2.
c~ i # & son Drop Date
1248 Ralph Avenue
.Erookly'a,.NY 11a13f .~ . . .
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R 3.V,4kejps i j g U7 ir4 f ation WDS phone number
A PG Box 39!
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0 Scotland, P'a. 172. . PamPewat*10034
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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 C 1,,) ' BAGS
SIZE Y d. CUBICYARDS
S. ,Generator Certification
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T 9. CONTRACTOR CERTIF1CAT IOi. ':: 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.
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Printed/Typed Name Title Signs Date
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10. Transporter #1 (Acknowledgement or receipt of materials) DEC Permit No.
O IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 1 215 JA-462
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T ~' : ` s Xt' ~DRT V`Ett ,.~'` ~!'F t' r~. 4 •G.,.. , / # /
E Print Name Title Signature 11T Date MiD t
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT#
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Printed/Typed Name
12. Discrepancy indication space
Title \ .--'gna1ure Data M!D/Y
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1 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
pIr )i[iAi Signature
Ykt Date (M!
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WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000119111
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