NYC 9/11 Public Portal Document
MANIFEST
11777
1. i >- Fii'V 'o '(* Wait and Load
,• •r Time In
*~"~• Time Out
2. Cc D d We Drop Date
BrocklyI,1VY 11231
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E
E 1W BlUe Ridge L,1 hl Ceiporat1o!!
R 3. st ts S) name, mailing address and physical site location WDS phone number
A Scot1i4Ps. 17254 Peimd # 100934
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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 4 CUBICYARDS
8. Ge rator Certification
ci
T 9. CONTRACTOR CERTIFICATION: I hereby declare that the contents of this consignment are fully and accutately described
R above by proper shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition for transport by
A highway according to applicable international government regulations.
N
S 2
Printed/Typed Name -Title Signature Date(M/D/Y)
P
10. Transporter # l (Acknowledgement of receipt of materials) DEC Permit No.
O I Y CORPOR TION • 110 5th Street, Brooklyn, NY 11 5 , P JA-462
R
T DRIVER h-46
E t me Title tore Date (M/DIY)
R
11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
W
A
I Prin ypedName Title St acute SCVDIY)
E 12. Discrepancyindication space
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
1
Y (tit ~.t, aa t _ •- ~1 -
Printed/Typed Name Title Signature Date (M/D/Y)
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000128664
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