Building inspection form for 119 Chambers Street

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, Cr 06480 TELEPHONE (860) 342-0667 • Fax: (860) 342-4866 Boston, MA 02114-2023 (212) 264-6770 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 FIRER CONIROI_ C. Address 309 BURNS AVENUE City City WANTAGH State NY p 11793 NEWER. NY Phone Number Telephone Number 1ET26Al2 OTI I2 GENERATING LOCATION Date Container Del. Date of Pickup Type of Container 490 YARD Address VOLUME Ins

CY Friable* Non-Friable ❑ City 119 CHA RS STRE4 Bag [ Drum ❑ Wrapped ❑ Other ❑ Il1E1Af YM- NY 1foQ7 Phone Number RQ, ASBESTOS, 9, NA2212, PG III INV #. FBI 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 lA-all s acts In proper condition for transport according to applicable international and national government regulations. AUTHORIZED SIGNATURE Transporter 1: Driver 9 Signature Registration #: MY 4It 139 AR StateI# Date: mt2AHI2

Acknowledgement of receipt of materials.

Transporter 2: Waste

Driver: #: Date: Acknowledgement of receipt of materials.

TEMPORARY STORAGE / TRANSFER FACILITY: WASTE MANAGEMENT N.E.E.T., INC. • 203 PICKERING STREET • PORTLAND, CT 06480 ,• PHONE: (800) 272-3887 PERMIT # SW 1130223 Received By: Certification of receipt of materials covered by this manifest. k Transporter 3: 1%N Lin

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

_Phone No:

Discrepancy If Any: Received by:___ Certification of receipt of materials covered by this manifest.

COPY 1 -GENERATOR NYC-WTC 000127363