EPA generator waste management form, undated

NYC 9/11 Public Portal Document

CT, MA, RI, VT, NH, ME E.P.A. AGENCY NY GENERATORS #99 48714 WASTE MANAGEMENT GENERATORS EPA Region 2 LOGANO EPA New England 1 Congress Street 290 Broadway, 26th Floor EMEFRGENCY RESPONSE P.O. Box 144 • Portland, CT 06480 New York, NY 10007-1866 (860)342-0667 • Fax:(860) 342-4866 Boston, MA 02114-2023 (212)264-6770 TELEPHONE Out of State 1-800-272-3867 (617) 918-1111 #1-800-272-3867

FB# 6024 ASBESTOS DISPOSAL & DOCUMENTATION FORM Job NumbeFIBER CONTROL INC. P.O. # GENEFi1►TQ Rl 9QW INC Contractor 3010 BURNS AVENUE Address 9210 4TH AVENUE Address WANTAGW µYim City BROJçJN. NY 112l City 1516178131 t?te Zip Phone Number Telephone Number 051232 Date Container Del. Date of Pickup GENERATING LOCATION 1W YARD Type of Containe11 Address 27 PARK PLACE VOLUME CV Friable Non-Friable 0 City 9tll fV YORK, NBtp Bag Drum ❑ Wrapped ❑ Other ❑ Phone Number

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, and are in all respects in proper condition for transport according to applicable international and national government regulations. AUTHORIZED SIGNATURE - • MA r-1fatR CONTROL INC. 3010 BURNS AVENUE WANIAQH. NY 11713 Transporter 1: 516-781-3000 address `` ~T 85n ~1 J .1 857 AL -4- Te&H*_ Driver: Registration #: Date: Sig ture State / # Acknowledgement of receipt of materials.

Transporter 2: Waste Ma ent N.E.E.T., Inc. PO Box 144, Portland, CT 06480 1-800-272-3867 / Driver: Registration 9 O/ ~~T .t-~ Date: j' Signature State / # Acknowledgement of receipt of materials.

TEMPORARY STORAGE / TRANSFER FACILITY: WASTE MANAGEMENT N.E.E.T., INC. • 203 PICKERING STREET • PORTLAND, CT 06481 PHONE: (800) 272-3867 PERMIT #5W 1130223 Received By: N/A Date: Certification of receipt of materials covered by this manifest.

Transporter 3: Name N/A Address Telephone # Driver: Registration #: Date: Signature State / # - / AcknowledgeptentDt r t of materials.

Landfill Name: No: Location: Approximate Volume of Asbestos Received: Discrepancy If Any: Received by: of receipt of materials covered by this manifest.

NYC-WTC 000126522