NYC 9/11 Public Portal Document
IESI NYt11RPORATION
110 5th Street Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST +~
11779 DATE %/i 3/L-
I.'. ii7óBi ay C f- EltVilro P Wait and Load
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xr,~,,,- r t~
• New Y N. :E . Time In
Time Out
I 2. C a d )ddk Drop Date
I'Q l'l 11236
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E • _ IE& Pa Blue Ridge Ltll tc ll Corpwatioal
R . 3. t S) name, mailing address and physical site location WDS phone number
AT SCwtla~ Pt 172 P` l # l 00934
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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. # P 1 7. TOTAL QUANTITY
(RQ) WASTE ASBESTOS 9, NA2212,'III TYPE BAGS
SIZE CUBICYARDS
8. Generator Certification t
T. 9. CONTRACTOR CERTIFICATION: I hereby declare that 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 condi ' n for transport by
A highway according to applicable international government regulations.
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$ Printed/Typed Name Title Signature Date M/D/Y K
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10. Transporter #I (Acknowledgement of receipt of materials) - - DEC P _ •t No.
C IESI NY CORP RATION •. 110 5th Street, Brooklyn, NY l
R
T ' ,~ DRIVER
E Mnted/F Name Fide ig n Date M/D
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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T
E
Printed/r
12.
Name
Discrepancy indication space
Tit a acute Date.(MIDIY)
S
T 13. Waste disposaJ. site owner or operator: Certification of receipt of.asbestos materials coveted by this manifest except as noted in item #12
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_
Printed/Typed Name Tide Signature Date (M/D/Y)
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000122687
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