NYC 9/11 Public Portal Document
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IESI NY-.COf ORATION I
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697 f
MANIFEST
11108 DATE
owner Wait and Load
1 J 5i1rU LOS S5b1Cet of Fkvioma!>tt
Time In
N Y New York, N.Y. Protection
Time Out
I 2. Drop Date
1248 Ralph Aveane
G Brooklyn, NY 11236
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N
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R 3. Wpsttyispgssl site,(,11J,QS) name, mailing address and ph sical site ovation WDS phone number
A jj'' t~~iOO~z ~~ yyyy
T Scotland, Pa. 17234 Permit # 100434
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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
5. Description of materials
6.VEH. LIC. # 7. TOTAL QUANTITY
(RQ) WASTE ASBESTOS 9, NA2212, III TYPE - BAGS
SIZE CUBIC YARDS
8. Generator Certification
T 9.0 NTRACTOR CERTIFICATION: I hereby declare that the contents of this consignment are fully and accutately described
R abov by r shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition for transport by
A high c9Øf g to applicable international government regulations.
N
1
S Printed/Typed Name Title Signature Date (M/D
P
10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No.
0 IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 1)2 15 JA-462
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E Printed/Typed Name Title / ~sinumre Date M/D/Y 462
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC7ERMIT #
W
A '►
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T Printed/Typed Name Title Si ore Date M/D/Y
E 12. Discrepancy indication space
4
S
T 13. Waste disposal site owner or operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
E
PrintedcrypeName file Signature Date (M/D )
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000127898
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