NYC 9/11 Public Portal Document
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IESI NY CORPORATION
110 5th Street • Brooklyn, NY 11215 Q .
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST r;
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DATE
L Job Site Address owner's name Wait and Load
5 I"i t? ` at i ~, t i. =Y tdTi lft f rl :: Time In
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Time Out ii,'
I 2. Contractor's name and address
I s )'t I( t
Drop Date
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R 3. Waste disposal site (WDS) name, mailing address and physical site location WDS phone number
A
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4. Name and address responsible agency (Local. District or EPA Office whPe 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 (1( c3 '.' _i SAGS
SIZE %: ; CUBIC YARDS
8. Generator Certification
T 9.CONTRACTOR CERTIFICATION: I hereby declarethat 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.
S Printed/ Name /V Title _~—~' Si a Date
P 10. spotter #I (Acknowledeemeat of te«ipt of maaial:)
Transporter j DEC Permit No.
0 IESI NY CORPORATION • 110 5th Street, Brooklyn,~iY 1 - 1 NI____
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T d °' DRIVER 4,• ,. C 11 1O
E F int Ns a Title ature Date M/D/Y
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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S 4 `
Pnntcd/TypedNme Title Sign sre. ' Date(M/D/Y)
T
E 12. Discrepancy indication space
T 13. Waste disposal site owner or operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
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Printed/Typed Name Title Signature Date (M/D/Y)
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000120421
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