EPA generator registration form, undated

NYC 9/11 Public Portal Document

CT, MA, RI, VT, NH, ME E.P.A. AGENCY NY GENERATORS #99 48722 WASTE MANAGEMENT GENERATORS ..e 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#Ca ~ ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number P.O. # GENERATOR/BUILDING OWNER Contractor FIBER CONTROL INC. CEDAR MANAGE NT 3010 BURNS AVENUE Address 20 VESEY STREET Address WANTAGH NY Zip 11793 City NEW W K. NY 11 City State (516)781-3000 Phone Number Telephone Number Date Container Del. Date of Pickup GENERATING LOCATION Type of Container 100 YARD Address VOLUME CV Friable,' Non-Friable 0 179 BROADWAY city NEW &. NY ioodP Bag. ' Drum ❑ Wrapped ❑ Other ❑ Phone Number INV #. F1027 Ids 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 1: FIBER CONTROL INC. VENUE-W*MTACH, NY 11733 Address Driver: ration #. NY 1480 138 AR Date: State / # Acknowledgement of receipt of materials.

Transporter 2: Waste Management N.E.E.T., Inc., PO Box 144, Portland, CT 06480 1-800-272-3867

Registration #: _Date: State! # Acknowledgement of receipt of materials.

TEMPORARY STORAGE / TRANSFER FACILITY: WASTE MANAGEMENT N.E.E.T., INC. • 203 PICKERING'STREET • PORTLAND, CT 06480 PHONE: (800) 272-3867 PERMIT # SW 1130223 Received By: r•i Date: Certification of receipt of materials covered by this manifest.

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

Landfill Name: S r Phone No: Location: 72ukt-3 W 7A/S9t Permit#: Approximate Volume of Asbestos Received: " ' C Discrepancy If Any: Received by: Date: _ P~ a~ Certification of receipt of materials covered by this manifest.

GENERATOR

NYC-WTC 000122788