WTC property inspection form, 67 Greenwich Street

NYC 9/11 Public Portal Document v ,_d ',J l «-' jV t -r

NYDEC 1A-371 NYDCA 483056

c beLo (man orLation o. Inc. P.O. BOX 1044 TOLL FREE PHONE 631-924-5050 HAMPTON BAYS, N.Y. 11946 1-800-755-OATC FAX 631-924-5085 "EMERGENCY NUMBER"

Waste M nifest # Job # Floor or Location Cust # - _

1. Work Site Name and Mailing Address Owner's Name, _Addrgss-Phone Number

Contractor's Name, Address Waste Disposal Site

RTD(B O7T WV 2( 3O cc:..LEcE - `-, .:

Name and Address of Responsible NESHAPS Agency Other ❑

U.S. EPA REGION II, 290 BROADWAY, NEW YORK, NY 10007 Description of Materials Bags - Cubic Yds. -

RQ Waste Asbestos, Class 9, NA2212, PGIII ❑ Other Drums or Tons - OTHER - ❑ RQ Waste White Asbestos, Class 9, UN2590, PGIII Special Handling Instructions and Additional Information

OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, marked and labeled and are in all respects in proper condition for transport by highway according to applicable international government regulations. ' 1

r~ >~ x Signature 7-2 cZ Printed/Typed Name itle Date (M/DD/YY) Transporter 1 (Acknowledgement of Receipt of Materials) Telephone No. Company Name and Address Signatur 631-924-5050 ASBESTOS TRANSPORTATION CO., INC. P.O. BOX 1044 Printed Name: ~/ ate HAMPTON BAYS, NY 11946 Title: DRIVER Transporter 2 (Acknowledgement of Receipt of Materials) Telephone No. Company Name and Address Signature: '~ 631-924-5050 ASBESTOS TRANSPORTATION CO., INC. P.O. BOX 1044 Printed Name, /4/ ~~- ` ,Date HAMPTON BAYS, NY 11946 Title: DRIVER Discrepancy Indication Space:

Waste Disposal Site Owner or Operator's Certification (Receipt of Above Waste Accepted) --)- ; - r Telephone No. : ~... Signature:

Printed Name: Date 79~oZ Company Name and Address Title: S

NYC-WTC 000128306