NYC 9/11 Public Portal Document
I
a IESI NY CORPORAON
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
1114 990 DATE_
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1. Job Site Address Owner's name Wait and Load
111 Fulton Street Dept Of Em-11.10 Pt edit'111 Time In
New Yotk, . V.
Time Out
2. C tat Drop Date
gticlg T ai5~ 4Y& Son
1148 Ralph Avelltaw
t rooktyn; NY 113Ô Ip
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R 3. p s t~ttiE;tl'natlit~ a d~yR ?lltdtdl"~tion WDS phone number
A P.O. Box J99
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O Scotland. Pa. 172'4 !~yeS in 1t f' 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 CUBIC YARDS
8. Generator Certification
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. ;
Printed/Typed Name Title- Signature Date (M !y
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10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No.
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R IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 1x215 JA-462
T 1 ! `'/ -DRIVER .r ~, /~c►, .
E Printed/fyped Name Title Signature j 1 Date (M/D/Y) '1
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II. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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T Printed/Typed Name Title Signature Date M/D/Y
E 12. Discrepancy indication space
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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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Printed/ryped Name
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Title Signature Date (M/D )
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WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000128727
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