Asbestos disposal form, generator, 2002

NYC 9/11 Public Portal Document

CT, MA, RI, VT, NH, ME E.P.A. AGENCY NY GENERATORS #99 48723 WASTE MANACiWPV GENERATORS EPA Region 2 LOGANO EPA New England 1 Congress Street 290 Broadway, 26th Floor New York, NY 10007-1866 EMERGENCY RESPONSE P.O. Box 144 • Portland, CT 06480 (860)342-0667 • Fax:(860)342-4866 Boston, MA 02114-2023 (212) 264-6770 TELEPHONE Out of State 1-800-272-3867 (817) 918-1111 #1-800-272-3867

FB# 6.2.5"6 ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number GENERATORIBUILDING OWNER Contractor BARCLAY STREET REALTY Address Address 3010 BURNS AVENUE 1200 UNION TPKE city e Zip City WANTAGH State NY Zip 11793 NEW HYDEPARK. NY 11040 Phone Number Telephone Number 78180 00t202 06 2 GENERATING LOCATION Date Container Del. ____________Dateof Pickup Type of Container on YARD Address VOLUME 1 CY Friable Non-Friable ❑ city Wrapped ❑ Other ❑ NEW YORK•11(Y 1 Bag Drum ❑ Phone Number INV # F1027 r;'»i ' ri{.i li I certify the above named material does not contain free liquid as defined by 40 CFR part 260.10 or any applicable state law, is not a hazardous waste as defined,by 40 CFR part 261 or any applicable state law, has been properly described, classified and packaged, and is in proper condition for transportation according to NESHAP standards for asbestos waste disposal found in 40 CFR part 61.150. Shipper's Certification: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national government regulations. 'w\ AUTHORIZED SIGNATURE___________________________________________ Transporter 1: a,RFR CONTRAI INC 3010 RttR.N9AVEM C-iN141ff?f%GH• NY 11793 516781-3000 Name Address Telephone # Driver Registration #: NY 1480139 AR Date: (16125102 Signature State / # Acknowledgement of receipt of materials.

Transporter 2: N.E.E.T.. Inc. CT 06480 1-800-272-3867

# _Date:________ Date: State / # z Acknowledgement of receipt of materials.

TEMPORARY STORAGE / TRANSFER FACILITY: WASTE MANAGEMENT N.E.E.T., INC. • 203 PICKERING-STREET • PORTLAND, CT 0648( PHONE: (800) 272.3867 PERMIT # SW 1130223 Received By: Date: Certification of receipt of materials covered by this manifest.

Transporter 3: Address Driver: Signature state / # Acknowledgement of receipt of materials.

Landfill Name:.5 ALLj Phone No: 16 --47~I -- Z / Location: IJ j !k f4 /39Z Permit #: /Qao~ oa D7/G/lS43

Approximate Volume of Asbestos Received: Discrepancy If Any: Received by: Date: 2/'i Certification of receipt of materials covered by this manifest.

COPY: - GE;~ERXTOR

NYC-WTC 000119788