NYC 9/11 Public Portal Document
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• IESI NY CUR OR ATION
110 5th Street • Brooklyn, NY 11215
MANIFEST
Phone: 718-522-2263 • Fax: 718-522-2697
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11107 DATE
1. Job Site Address Owner's name Wait and Load
123 Hilton Street Deptof Eaviroanoataal Time In
N Y New' ork, N Y. Prc1eCtioo Time Out
2. C Drop Date
13L91fesllu! !>s1TI21Ji~ &
1248 Ralph Ague
E &ooklyn, NY 11236
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R 3. W Bt dk )Bgtion WDSphonenumber
A P.Q. Boer 399
o Scotland, Pa 17234 Pere 01 1934
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4. Name and address responsible agency (Local. District or EPA Office where notification was sent)
US EPA 290 Broadway, New York 10007
S. Description of materials 6.VEH. LIC. # 7. TOTAL QUANTITY
(RQ) WASTE ASBESTOS 9, NA2212, III TYPE
SIZE CUBICYARDS
8. Generator Certification
T 9.C NT CTOR CERTIFICATION: I hereby declare that the contents of this consignment are fully and accutately described
R abov by hipping name and are classified, packed, marked and labeled, and are in all respects in proper condition for transport by
A high o o livable international government regulations.
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S printedrryped Name Title Signature Date t
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10. Transporter #1 (Ac n owledaematt of icecipt of ma rials) I DEC Permit No.
R IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 215 I J
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R n yped ame Title Si ature Date
11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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12.
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Title
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T 13. 'Waste disposal site owner or operator. Certification of receipt of asbestos materials covered by this manifest except as noted in Item #12
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ated/I T de Signature Dace ( )
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR GOLD:JOB SITE
NYC-WTC 000127835
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