NYC 9/11 Public Portal Document
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IESI NY CORPORATION
110 5th Street • Brooklyn, N'N 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
11105 DATE
I. Job Site Address Owner's name Wait and Load
119 Fulton Street Dept of En%jrC mental Time In
N Y New York, N.Y. Protection Time Out
2. C rector's name aa}addregs Drop Date
1248 Ralph Avenue
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Brooklyn, NY 11236
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R 3. W ijphtl c,etJji j1 ts tion WDS phone number
A P.O. Bole 399
O Scotland, Pa. 1.254 Permit # 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 'BAGS
SIZE CUBIC YARDS
8. Generator Certification
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T 9. CO TRACTOR CERTIFICATION: I hereby declarethat the contents of this consignment are fully and accutately described
R above y p ~er s ' ping name and are classified, packed, marked and labeled, and are in all respects in proper condition for transport by
A highwa a r to appli ble international government regulations.
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S Printed edName Title Signature Date M/D . TT y
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10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No.
O IESI NY CORPORATION • 110 5th Street, Brooklyn, NAG 215 JA-462
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Printed/ryped Name
________ ___________
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Title Si nature Date M/D/Y
R 11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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Printed/l Name Title Sigiattire Date /DIY
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E 12. Discrepancy indication space
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T 13. 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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nted/ryped Name Title ignature Date (M/
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000119599
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