NYC 9/11 Public Portal Document
CT, MA, RI, VT, NH, ME
E.P.A. AGENCY
NY GENERATORS
#99 4871
GENERATORS
EPA Region 2
EPA New England 290 Broadway, 26th Floor
P.O. Box 144 • Portland, CT 06480 I Congress Street New York, NY 10007-1886
EMERGENCY RESPONSE
(860) 342-0667 • Lax: (860) 342-4866 Boston, MA 02114-2023 (212) 284-6770 TELEPHONE
Out of State 1-800-272-3867 (617) 918-1111
#1-800-272-3867
FB# i40 ASBESTOS DISPOSAL & DOCUMENTATION FORM
Job Number P.O. # GENERATOR/BUILDING OWNER
Contractor FIBER CONTROL INC.
Address
Address 3010 BURNS AVENUE 10-12 (DRTLANI .STREET .
WANTAGH City State. Zip
City State NY Zip 11793 NEW YORK, NY
C3' 7'81.3000 Phone Number
Telephone Number
UTF Q
Date Container Del. Date of Pickup GENERATING LOCATION
Type of Container 100 YARD
VOLUME 3 CV Friable Non-Friable 0 City p
Bag Drum 0 Wrapped 15 Other 0 l it YORK. N
Phone Number
_, A22'#2: PG IJa INV #. F1059
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 are in sin proper condition for transport according to applicable international and national
government regulations.
AUTHORIZED SIGNATURE LA
Transporter 1:
Name elephoneS
Driver Registration #: NY 1480139 AR Date: T 07124*12
Signature State / #
Acknowledgement of receipt of materials.
Transporter 2: Waste Mapagefnent N.E.E.T., Inc.. PO Box 144. Portland. CT 06480 1-800-272-3RR7
Driver:
TEMPORARY STORAGE t TRANSFER FACILITY: WASTE MANAGEMENT N.E.E.T., INC. • 203 PICKERING'STREEf • PORTLAND, CT 0648C
PHONE: (800) 212-3867 PERMIT # SW 1130223
Received By: 011 __Date:
V Certification of receipt of materials covered by this manifest.
Transporter 3: . % /
Driver: 0
Date:
State /#
of receipt of materials.
Landfill Name:
Location: —d
Approximate Volume of Asbestos Received:
Discrepancy If Any: _ t
Received by:
Certification of receipt of materials covered by this manifest.
NYC-WTC 000126303
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