202 BROADWAY 1001221, 79/19

NYC 9/11 Public Portal Document

I Job Site Address Owner's name Wait and Load 202 Bosdway . $ Time In .. . Time Out

2. c g Drop Date :.

NY 1123 E R 3. Waste disposal site (WDS) name, isratling a4dt ess and physical site location WDS phone number:. . .

R. SCttkfld,Pa

4. Name and address responsible agency (Local,District or EPA Office where notification was sent) . .

US EPA 290 Broadway, New York 1`000?

5. Description of materials . 6 VEi; LIC # .: 7.. TOTAL QUANTITY ., ;ME . . ~ ' ,. (RQ) WASTE ASBESTOS 9,NA2212 ITI BAGS SIZE CUBICYARDS S. Generator Certification - . .

T 9.CONTRACTOR CERTIFICATION: I hereby declare that the contents .of this consignment are frilly and accutately described R above by proper shipping name. and classified, packed, marked labeled, and are in all respects in proper coition for transport by . A. highway according to applicable international government regulations N 'il gaw. S Printcd!Fyped Name . Title Signature Date P 10. Transporter #1 (Aoknowledgemeat of receipt of matenals) DE 0. D Y CORPO TION * 10 5th Street,.Brooklyn, NY°112 R T. .,r } ~► DRIVER m : E n ame; ' fide _ _ _ _ __ __bate (MIDIY) R 11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT. # :. IESI 2 W

S Prin ame Title :. csi Date T E 12. Discrepancy indication space • S , I T 13. Waste disposaLsite owner or operator Certification.of receipt of asbestos materials covered by.this manifest except as noted in item #12 E 4 s 4l Jo Printed/fyped Name Title Signature Date (M/D/Y).

WHITE LANDFILL • GREEN:IESI •PINK:GENERATOR • YELLOW CONTRACTOR.• GOLD:JOB SITE:

NYC-WTC 000123242