204 BROADWAY 1001222, 79/21

NYC 9/11 Public Portal Document IESI NY CORPORATION 110 5th Street • Brooklyn, NY 11215 :Phone: 718-522-2263 • Fax: 718-522-2697 MANIFEST 11784 DATE 8/13/02 1. Job Site Address 204 Broadway New Yerk, N.V. Owner's name Dept Of Enviro Frotection Wait and Load Time In Time Out 2. Contractor's namé and address Benjamin Kurzban & Son 1248 Halph Avenue Brooklyn, NY 11236 Drop Date A T 3. Waste disposal site (WDS) name, mailing address and physical site location WDS phone number R § IESI Pa Blue Ridge Lendili Corporation. RO. Box 399 Scotland, Pa 17254 Permit #100934 4. Hame and address responsible agency (Local, District or EPA Office where notification was sent) US EPA 290 Broadway, New York 10007 5. Description ofaiaterials (RQ) WASTE ASBESTOS 9, NA2212, III 6.VEH. LIC.# 2967619 7. TOTAL QUANTITY TYPE (ose)) SIZE 40 BAGS 8. Generator Certification box. CUBICYARDS 4024 El 11Y79 9.CONTRACTOR CERTIFICATION: I hereby deciare that the contents of this consignment are fully and accutately described above by proper shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition for transport by highway according to applicable international government regulations. . Printed/Typed Name Title Signature " Date (M/D/Y) 8/13/62 10. Transporter #1 (Acknowledgement.of receipt.of materials). IEȘINY CORPORATION • 110 5th Street, Brooklyn, NY41 DECPEmi: No1 N2A62 banno DRIVER Printed/TypesT Sullb (ema MACaE Date (M/D/Y) 8/5/2 11. Transporter #2 (Acknowledgement ofreceipt of materials) DEC PERMIT # JEST 00 8/78/02 NIA6) Printed/Typed Name Title Date (M/D/Y) 12. Discrepancy indication space 13. Waste disposal site owner oř operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12 aadikik Printed/Typed Name Jetekigper Titie Sienature KKK 8/16/02 Date (M/D/Y) WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE NYC-WTC_000123278