Asbestos inspection form, 175 Broadway, Oct 2001

NYC 9/11 Public Portal Document

CT, MA, RI, VT, NH, ME E.P.A. AGENCY NY GENERATORS #99 48720 WASTE MANAGEMENT _• 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 (617) 918-1111 #1-800-272-3867

FB# C'Z ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number P.O. # GENERATORBUILDING OWNER Contractor FIBER CONTROL INC. CENTURY REALTY INC 3010 BURNS AVENUE Address 140 FULTON STREET Address WANTAGH NY Zip 11793 City NEW 1~tK. NY 100# City State (5 781-30W Number Telephone Number Date Container Del. Date of Pickup GENERATING LOCATION

Type of Container 100 YARD VOLUME 1n CV Friable,' Non-Friable ❑ city NEW ftK. NY iwidt Bag. " Drum ❑ Wrapped ❑ Other 0 Number INV * F1027

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. ~-----_, AUTHORIZED SIGNATURE : t 1: FIBER CONTROL INC.

Driver: Registration #. NY 1480 139 AR Date: Slant a State / # Acknowledgement of receipt of materials.

Transporter 2: N.E.E.T.. I

#: 'J `ice _ef t Date: State / # / 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: 'J j t Date: Certification of receipt of materials covered by this manifest.

Transporter 3: Name Address Telephone # Driver: Registration #: Date: Signdture State / # Acknowledgement of receipt of materials.

Landfill Name: aS .f/-{{ OA,frl tic Phone No: Location: "cV JrJS'UI I11 r,7 - /S'1'& Permit#: Approximate Volume of Asbestos Received: Discrepancy If Any: ' Received by: Date: L 7/ 4W. Certification of receipt of materials covered by this manifest.

COP. I - GENERATOR

NYC-WTC 000122644