EPA generator registration form, undated

NYC 9/11 Public Portal Document

-1'T/►1A WASTE MANAGEMENT CT, MA, RI, VT, NH, ME GENERATORS E.P.A. AGENCY NY GENERATORS #99 48721 • EPA Region 2 LOGANO EPA New England 1 Congress Street 290 Broadway, 26th Floor EMERGENCY RESPONSE P.O. Box 144 • Portland, CT 06480 New York, NY 10007-1866 (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# 6GZ,Sr- ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number P.O. # I GENERATOR/BUILDING OWNER Contractor FIBER CONTROL INC. CENTURY REALTY INC Address Address 3010 BURNS AVENUE 140 FULTON STREET City City WANTAGH State NY Zip 11793 NEW K. NY 100 L5IG)781.3000 Phone Number Telephone Number Date Container Del. Date of Pickup GENERATING LOCATION Type of Container 1111 YARD Address VOLUME 1R CY Friable' Non-Friable ❑ NEW177 BROADWAY City Bag% Drum ❑ Wrapped p Other ❑ $? K• NY 1 Phone Number \.2212. PCi i • . 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.

Transport) 2:,14(aste Management N.E.E.T., Inc., PO Box 144, Portland, CT 06480 1-800-272-3867

Registration #: fY)~/ 215' Date: Signature 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: 1`\I j Date: Certification of receipt of materials covered by this manifest.

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

Landfill Name: 6 At L eGAe / e's Phone No: _/1"/7'7— 2331 Location: Th tl kiSVI)IG 74 / 2.x'" Permit #:,_C~l>O&/ !O _ Approximate Volume of Asbestos Received: ey Discrepancy If Any: Received by: çA - Date: e'cO/ ?/) Certification of receipt of materials covered by this manifest.

CO.':: 3ENETATOR

NYC-WTC 000122753