Asbestos disposal form, 2002

NYC 9/11 Public Portal Document

CT, MA, RI, VT, NH, ME E.P.A. AGENCY NY GENERATORS #99 49006 WASTE MANAGEMENT GENERATORS EPA Region 2 LOGANO EPA New England 290 Broadway, 26th Floor EMERGENCY RESPONSE P.O. Box 144 • Portland, CT 06480 1 Congress Street 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# ~p ASBESTOS DISPOSAL & DOCUMENTATION FORM Job Number O.# GENERATOR/BUILDING OWNER Contractor FIBER CONTROL INC. lY,tll:>a~c.~axlu~ta~llrr~ulel~lrz._._.- 3010 BURNS AVENUE Address Address city City WANTAGH State--!Y Zip 11793 (516)781.3000 Phone Number Telephone Number Date Container Del. Date of Pickup GENERATING LOCATION Type of Container 100 YARD Address 144 CHAI. ER5 STREET VOLUME 114 CV Friable' Non-Friable ❑ City NEW Y ?, K. NY 100' Bags 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 11733 516-7813000 N e Address Telephone # Driver: Registration #: NY 1480 139 AR Date: 07Q4A)2 Signature State / # Acknowledgement of receipt of materials.

Transporter 2:

Driver: Registration #: 2_,,~/ /moo Date: ianature State#/ Acknowledgement of receipt of materials.

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

Transporter 3: Address Telephone # Driver: ,tration #: Signature State / # of receipt of materials.

Landfill Name: Phone No: Location: Approximate Volume of Asbestos Received: Discrepancy If Any: ./ ~,~ , Received by: vv L A Certification of receipt of materials covered by this manifest.

COPY 1 - GENERATOR NYC-WTC 000127295