NYC 9/11 Public Portal Document
y. §0 IESI NY CORPORATION
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST / /
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DATE /2 /
owners name Wait and Load
1. Job Site Address
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'~'` ` `i t►t # Time Out
2. Contractor's name and address Drop Date
Nees' (:)t#.ST<'t I. t
3. Waste disposal site (WDS) name, mailing address and physical site location WDS phone number
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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. # 7. TOTAL QUANTITY
(RQ) WASTE ASBESTOS 9, NA2212, III TYPE "BAGS
SIZE CUBIC YARDS
8. Generator Certification
9.CONTRACTOR CERTIFICATION: I hereby declare that the contents of this consignment are fully and accutately described
t above by proper shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition for transport by
highway according to applicable international government regulations.
Printed/F Name Title Sigiature Date
10. Transporter #1 (Acknowledgement of receipt of materials) DECPemit No.
IESI NY CORPORATION 110 5th Street, Brooklyn, NY 1I J.,15
Printed/Typed Name Title S re Date
11. Transporter #2 (Acknowledgement orreceipt of materials) DEC PERMIT # y
t
Printed/TysedNane Title Si re ~`` Dst(M/D/Y)
12. Discrepancy indication space ;F
13. Waste disposal site owner or operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
14 4 f. / f:': r
e
Printed/Typed Name Title Signntute Date (IVVD/Y)
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR - GOLD:JOB SITE
NYC-WTC 000120419
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