Waste manifest form for 102-104 Fulton Street

NYC 9/11 Public Portal Document

. FS N'' PORATION I 10 th Ser e Br ., onn : X 18 23203 Fax: 22 097 MANIFEST

l 1 r #'f „'• DATE

I. .1ti C , d ,. Stil- c)w tff Efl "i!"' .~2'a)f 'd! nWait and Load b4 i4 N' Time In Time Out

2. 1(f,tla Drop Date r d [itU+ Ii.r k1 ti,NY 11.236 G E

E fESI P6 Blue R.iOe Z.endfi l Corpai it s~ R 3. R stydis to ( S) name, mailing address and physical site location WDS phone number A c°irtl nd, P. 1 7S4 100934 T O R

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 mater als 6. VEH. LIC. # f 7. TOTAL QUANTITY .. (RQ) WASTE ASBESTOS 9, NA2212, III TYPE f BAGS SIZE t:s yr CUBICYARDS 8. Generator Ce tificai

T 9. CONTRACTOR CERTIFICATION: I hereby declare that the contents of this consignment are fully and accutately descrilwd R above by proper shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition for transport 13,; A highway according to applicable international government regulations. N N , _ Printed Typed Name Title Signature _ YYN0._ Date (M/D'Y) P O 10. Transporter #I (Acknowledgement of receipt of materials) DEC Permit No, I I Y CORPORAL TION • 1 10 5th Street, Brooklyn, NY 1L JA-462 DRIVER A t v {y R Transporter #2 (Acknowledgement otreceipt ot ~•, IP A W t _

Prmted~i vpec Nei tIe ~ nature Date (M/D Y) T @ E 12. Discre ane .,. i s - }'•..~

S ._._.._.__.._,.......,.,.~~. T 1 3. Waste disposal site owner or operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item # 12 E

: ,~1 Printed'Tvped Name Jt Tr . ¢. fit: ►r . Title Signature Date (MiD'Y)

WHITE:LANDFILL • t:;REEN:IESI • PINK:GENERATOR • YEI.LI.OW:CONTRACTOR • GOLD:JOB SITE

NYC-WTC 000128677