Waste manifest form for 57 Ann Street

NYC 9/11 Public Portal Document

IESI NY CORPORATION •

110 5th Street • Brooklyn, NY 11215 Phone: 718-522-263'*• Fax: 718-522-2697. "'' MANIFEST ,

11016 DATE 1. i,? ;s Owner's name Wait and.Icad 57 Ann S&e et Dept Of EaN'r Pri'' i' i ni Time InI N,w York • N.Y. ;Time cats

2. Contractor's name and address Drop Date,. i ~~2 Bkftto }.wzb~1 "$ S€ G 1248 Ralph Avenue N Brooklyn, N t 1236 E R 3. Waste disposal site (WDS) name, mailing address and physical site location . WDS phone number

T IESI Pa Blue Ridge LncU1ll C'ax Vt*h1ion o P.O. Box :399 R Si t d. P. 17254 Permit 0 ldO9_14

4. Name and address responsible agency (Local, District or EPA Office where notification was sent)

US EPA 290 Broadway, New York 10007

S. Description of materials 6.VEH. L // ~J '. # 6 r /- ✓!" 7. TOTAL QUANTITY (RQ) WASTE ASBESTOS 9, NA2212, III TYPE C E BAGS

8. Generator Certification SIZE Q ' ' L— 4 ) CUBIC YARDS

T 9. i t: i? t. ' E j2 f(F i i :. : {; ,' , . I hereby declare that the contents of this consignment are fully and accurately described - R above by proper shipping name and are classified, packed, marked and label dare in all respects in proper condition for ansport by A hi y ording to applicable internation4 government regulations. / S Printed/Typed Name Title Si re Date P 10.Transporter #1 (Acknowledgement of receipt of materials) DEC~ o, O IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 11215 NT C+< R r Name i r'{ DRIVER Title /Si Lq Date 7 t / 11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT # jj __( W ~

Prhitedrryped Name Tide Signature Daiâ(M/D/Y) T E 12. Discrepancy indication space

S ..w

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

1 /( 111:7_ 6PL±a:yp:e~d Name Title Signature ' Date (M/D/Y)

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

NYC-WTC 000119758