Waste manifest form for 57 Ann Street

NYC 9111 Public Portal Document

IESI NY CORPORA 110 5th Street • Brooklyn, NY 11215 i • Phone: "718-522-2263 • Fax: 718-522-2697 r t MANIFEST

11320 l DATE 4..

1. JohSite.-Address Owneesname Wait and Load

i7 Ann St.><eet Dept Of Eusr Ptotedion ,, New TY'L { , N. V Time Out

2. C ; 3ft li ractor's name n add Sn _7/~ Drop Date

1:.-6 Ralph Aw ue EN Bro

• _. yt1,'N\' 11 36 . _ ° 2 .[.:.

E R 3, W J It~~ad tion WDS phone number T T P0 Box : 9) O Sr..+th d, Pa. 17254 Pc Y t # 10393.1 R

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. LIC. # , 7. TOTAL QUANTITY (RQ) WASTE ASBESTOS 9, NA2212, III TYPE C o ' BAGS SIZE a L fL.- ,) CUBICYARDS 8. Generator Certification , o - ,0 1

T 9. CONTRACTOR CERTIFICATION: I hereby declare thane contents of this consignment are fully and accutate described R above by proper shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition fo by A highway according to applicable international government regulations. Z.... N 7 7- 141 S PtintecVTyped Name Title Signature Date P 10. Transporter #I (Acknowledgement of receipt of materials) DECO C12nit o. 0 SI NY CORPORATION • 110 5th Street, Brooklyn, 1 15 1~ JA-462 R T E '• Pnn l/j Name t f fl' DRIVER Title , a Si elute t --A Date M/D/Y 7/ Z .• R 11. Transporter #2 (Acknowledgement of receipt of materials) DEC PER1IIT # W A S Printedfryped Name Title Sigaltre Date T E 12. Discrepancy indication space

S I 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

fi' . J\L 1t, i` k ; 'nted/TypedName 11ITe Signature Date(M/D/Y) .

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

NYC-WTC 000119759