Asbestos disposal and documentation form header, EPA Region 2

NYC 9/11 Public Portal Document

E.P.A. AGENCY #99 48737 WViiii WASTE MANAGEMENT CT, MA, RI, VT, NH, ME GENERATORS NY 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, Cr 06480 (860) 342-0667 • Fax: (860) 342-4866 Boston, MA 02114-2023 (212) 264-6770 TELEPHONE Out of State 1-800-272-3867 (617) 918-1111 #1-800-272-3867

FB# ` ' ft o ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number P.O. # GENERATOR/BUILDING OWNER Contractor FIBER CONTROL INC. ESTATE OF WILLIAM STONE Address 110 CHAMBERS STREET Address 3010BURNS AVENUE City WANTAGH State NY Zip 11793 city NEW i&4K. NY 100 _16)791-3000 Phone Number Telephone Number O6Q2 07f 2 GENERATING LOCATION Date Container Del. Date of Pickup Type of Container 100 YARD Address VOLUME 1116 CV Friable ] Non-Friable ❑ city Drum ❑ Wrapped ❑ Other ❑ NEW !f8?K NY 10007 BagX Phone Number INV #. F1040 RQ, ASBESTOS, 9, NA2212, PG III 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 ects in proper condition for transport according to applicable international and national government regulations. AUTHORIZED SIGNATURE Transporter 1: FIBER CONTROL INC. O1O BU* S AVENUE WAN9 GH. MY 11795 516.781.3000 Name Telephone// Driver: Registration #: NY 480 139 AR Date: 072 4 Signature State / # Acknowledgement of receipt of materials.

Transporter 2: Waste M e nt N.E.E.T. Inc. PO Box 144, Portland, CT 06480 1-800-272-3867 4 ~7 Driver: Registration #: 00 ~ /!~' AI U Date: c ~- ~Z- i lure State / # Acknowledgement of receipt of materials.

TEMPORARY STORAGE / TRANSFER FACILITY: WASTE MANAGEMENT N.E.E.T., INC. • 203 PICKERING-STREET • PORTLAND, CT 06480 1 % PHONE: (800) 272-3867 PERMIT # SW 1130223 Received By: Certification of receipt of materials covered by this manifest.

Transporter 3: Address Driver: #: Date: Signature State / # of receipt of materials.

Landfill Name: No: Location: Approximate Volume of Asbestos Received: Discrepancy If Any: Received by: /ALI(.JtL_-( 7- 'L, -o---- Certification of receipt of materials covered by this manifest.

COPY 1 - GENERATOR NYC-WTC 000121987