NYC 9/11 Public Portal Document
1. 3 Owner's name Watt and Load'
New ` N..y:. Time In
Time Out . . .
2. & Drop Date
124S Ralph Avuie
&1YI S NY I123
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A 3. )nan mailing address and ph sical site ovation. WDS phone number
T <SCOtiaZdPa. 17254 IflUt 1 1.
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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
S. Description of
6.VEH: LIC. # 7. TQTAL•QUANTITY
(RQ) WASTE ASBESTOS 9, NA2212,:III TYPE -BAGS
.• SIZE .
: cu ci YAItDS
8. • Generator Certification
T 9.CONTRACTOR CERTIFICATION: I hereby declare that the contents of this consignment fully and.accuta ely.described
above by proper shipping name and are classified, packed, marked and labeled,and are in all respects in proper condition .for ttansport by
are
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A highway according
to applicable international government regulations..•
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$ PrintediTyped Name : Title Signature Date
0R IE 10. Transporter #1 (Acknowledgement of receipt of materials
Y CORPORATION •.•110 5th Street, Brooklyn, N
. DEC Permit No.
JA-
T Y DRIVER•
. . .. ' Side ;. e(MID 7 2
11. of
Transporter #2 :(Acknowledgement receipt of materials) .;
DEC PERMIT #
W
T nie • k 1
E 12. Discrepancy indication space t'
S
T 13. Waste disposal site owner or operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
E
Printed/Typed Name Title Signature Date (It9/DFY)
WHITE:LANDFHLL • GREEN:IESI •.PINIC:GENER.ATOR • YELLOW:CONTRACTOR • GOLD:JEOB -SITE
NYC-WTC 000122880
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