NYC 9/11 Public Portal Document
IESI NYtthPORATION '
110 5th Street • Brooklyn, •NY 11215
Phone: 718-522-2263. Fax: 718-522-2697 .
MANIFEST
:
1' 761 DATE
1. J d Load .
Y , Y. Time In
Time Out
Drop Date
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1
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R : 3. i i ) mailing and p iced site oration WDS phone number
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T ~ ,Pa 17254 0100934
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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 10009:
S. Descriptionofniaterials
7: TOTAL QUAN?`IT,Y
(RQ) WASTE ASBESTOS 9, NA2212, III TYPE BAGS'
SIZE C:UBICYARDS
8. Generator Certification
T 9.CONTRACTOR CERTIFICATION: I hereby declare that. the contents of this consignment are fully and -accutatelyr described
R above by proper shipping name and are classified,' packed, marked and:labeled, and are in'all respects in proper condition for transport by .
A highway according to applicable international government regulations.
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S Printedfr Name _. : rtte Si stare Date
P
O i0. TT8I1spOft~1` #1 (Acknowledganent of receipt of
DEC Permit No.
R NY CO ORATION • .1 is 5th Street, Rrookly JA=462
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DRIVER
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11. Transporter #2 (Acknowledgement of receipt of materials) S
,f DEC PERMIT' #.
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12.
`Name
Discrepancy indication space
Title
...
' &_ SIL
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T 13. Waste disposalsite owner or operator. Certification of reO ipt of asbestos materials covered by this manifest except as noted in item #12
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Printed/Typed Name Title Signature' Date (M/DIY)
WffiTE:LANDFILL • GREENJESI • PINK GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000122986
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