NYC 9/11 Public Portal Document
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=~- IESI NY-CORPORAI 10 —
110 5th Street • Brooklyn, NY 11215
Phone: •118-522-2263 • Fax: 718-522-2697
MANIFEST
1 52 0 DATE
I. ;,,b Site Address Owner's name Wait and Load
~ 7 AIm Street Dept Of Fntr Fit otectir n im
Nev ''4)ik , t . Y
iN Time Out
2. Conlractor's name aqqt~( address Drop Date
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1 2-48 Ra'ph Avenue
rtvklytli, -NY I tj 36 °°
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R 3. WI1e ji a¢dgliraicals igrction WDS phone number
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T P 0. Box 399
O Sr&'tt l:Indd. Pa. 1 J34 tT1!t# 1O931
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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. # 11
' 7. TOTAL QUANTITY
(RQ) WASTE ASBESTOS 9, NA2212, III TYPE {y r l f BAGS
SIZE a `! fL. , %} CUBICYARDS
8. Generator Certification a 3a
T 9. C O, i P.A C T G R C E R l' I F I C .A T i (_):' ~. I hereby declare thathe contents of this consignment are fully and accutatety described
R above by proper shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition fo'transp by
A highway according to applicable international government regulations.
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S Printed/Typed Name Title t Signature Date M/D/Y
10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit Io.
O 'IESI NY CORPORATION • 110 5th Street, Brooklyn, 1 15 ; JA-462
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4i /i4/ n DRIVER : t ` 7/ Z Z
i Printed/r}4)ed Name Title 'Si gnature Date M/D/Y
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC PE IT # .
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S Date(M/D/Y)
Printed/Typed Name Title Signature
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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rinted?yped Name Titre '~ Sigtiature Date (M/D/Y) .
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000119725
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