Asbestos disposal form, 2002

NYC 9/11 Public Portal Document

E.P.A. AGENCY CT, MA, RI, VT, NH, ME NY GENERATORS WASTE MANAGEMENT GENERATORS EPA Region 2 LOGANO EPA New England 1 Congress Street 290 Broadway, 26th Floor New York, NY 10007-1866 EMERGENCY RESPONSE P.O. Box 144 • Portland, CT 06480 (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# ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number P.O. # GENERATOR/BUILDING OWNER Contractor FIBER CONTROL INC. HERBERT MOSKOWITZ 3010 BURNS AVENUE Address 70 LAFAYETTE STREET Address WANTAGH NY Zip 11793 city NEW %R K. NY 100iñ'p City State p16)781.3000 Phone Number Telephone Number Date Container Del. Date of Pickup GENERATING LOCATION

Type of Container 100 YARD I Address 144 CHAV ERS STREET VOLUME 114 CV Friable' Non-Friable ❑ City NEW K. NY 100' Bag)' Drum ❑ Wrapped ❑ Other 0 Phone Number INV * F1059 RQ, ASBESTOS, 9, NA2212, PG III 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 Transporter 1: FIBER CONTROL INC. _ 3010 BURNS A . NY 11735 N e Address Telephone # Driver: Registration #: NY 1420 139 AR Date: 07124I2 Signature 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 #: 0 Date: ignature State / # Acknowledgement of receipt of materials.

TEMPORARY STORAGE / TRANSFER FACILITY: WASTE MANAGEMENT N.E.E.T., INC. • 203 PICKERING,STREET • PORTLAND, CT 06480 1 I n PHONE: (800) 272-3867 PERMIT # SW 1130223 Received By: Certification of receipt of materials covered by this manifest.

Transporter 3: ._ ♦ ► _

Driver: #: Date: Signature State / # of receipt of materials.

Landfill Name: No: Location: Approximate Volume of Asbestos Received: Discrepancy If Any: — , ////~~~ii ~GG Received by: d~ Certification of receipt of materials covered by this manifest.

COPY 1 - GENERATOR NYC-WTC 000127295