Manifest form for 57 Ann Street, 2002

NYC 9/11 Public Portal Document

IESI NY CORPORA14ON 110 5th Street • Brooklyn, NY 11215 Phone: 718-522-2263 • Fax: 718-522-2697 MANIFEST ,

, 1 1479 DATE

1 • Job Site Address ' Owner's name Wait an~Load 57 Mn Streiet Dept Of Eiwwo Protecii Time In NeWY4e'k,NY. Time : }

2. a Drop Date

124k Ralph AY el .%

.N E R 3, tion WDS phone number

O $cotlaald Pt 17254 Pe last 1009 R

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 A/IF 6.VEH. LIC. # 7. TOTAL QUANTITY

(RQ) WASTE ASBES S 9, NA2212, III TYPE BAGS CUBICYARDS 8. Generator Certification

T 9. CONTRACTOR CERTIFICATION: 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. N S Printed!rypedNaine Title Signature Date M/D P 10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No. 0 IE Y CORPORATION • 110 5th Street, Brooklyn, NY 11 15 R JA-462 ~T , DRIVER ,a E Print Name Title nature Date M/D!Y'` R 11. Transporter #2 (Acknowledgement ofreceipt of materials) DEC PERMIT # W

T Printedfryped Name Title ~S. ure Date D/Y E 12. Discrepancy indication space }

S t- T 13. Waste disposal site owner or operator: Certification ofreceipt of asbestos materials covered by this manifest except as noted in item #12 E

Printed/rypedName Title Signature Date(M/D/Y)

WHITE:LANDFILL • GREEN:JESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE

NYC-WTC 000119752