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NYC 9/11 Public Portal Document

E.P.A. AGENCY #99 CT, MA, RI, VT, NH, ME NY GENERATORS 48721 WASTE MANAGEMENT GENERATORS EPA Region 2 LOGANO EPA New England 1 Congress Street 290 Broadway, 26th Floor EMERGENCY RESPONSE P.O. Box 144 • PortIand, CT 06480 New York, NY 10007-1866 (860) 342-0667 • Fax: (860) 3424866 Boston, MA 021142023 (212) 264-6770 TELEPHONE Out of State 1-800-272-3867 (617) 918-1111 S #1-800-272-3867

FB# 'Z'S~ ASBESTOS DISPOSAL & DOCUMENTATION FORM. Job Number .O.#______ GENERATORBUILDING OWNER Contractor FIBER CONTROL INC. CENTURY REALTY INC Address Address 30101BURNS AVENUE 140 FULTON STREET city City WANTAGH State NY Zip 11793 NEW?K• NY 100i ' (516)781 = Phone Number Telephone Number Date Container Del. Date of Pickup GENERATING LOCATION Type of Container 100 YARD I Address VOLUME V!2 CY Friable' Non-Friable ❑ city Drum p NEW t K. NY 1 Bag Wrapped ❑ Other ❑ Phone 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 Transporter 1: Driver: # NY 1480139 AR Date: State / # Acknowledgement of receipt of materials.

2: T., Inc.. PO CT

Registration #. ft ? /O.?4 2c Date: ~ state / # Acknowledgement of receipt of materials.

TEMPORARY STORAGE / TRANSFER FACILITY: WASTE MANAGEMENT N.E.E.T., INC. • 203 PICKERING-STREET • PORTLAND, CT 06481 PHONE: (800) 272-3867 PERMIT # SW 1130223 Received By: IQ Pr Date: Certification of receipt of materials covered by this manifest.

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

Landfill Name: Location: t1Ic 1/)11Gy P4 !L P.c' Approximate Volume of Asbestos Received: 1 C y Discrepancy If Any: Received by: Date: cV/# Certification of receipt of materials covered by this manifest.

CO= ' - GENEr3ATOR NYC-WTC 000122741