NYC 9/11 Public Portal Document
IESI NY 6RPORATION
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
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1. i t, Owner's name Wait and Load
Ill Fulton Street Dept 01 EfwAr.) Pt Ct?r.?'!l Time In
Nev., Ytk. N Time Out
2. Ct qr, Drop Date
~attt<fla i~ill & slit,
l 24 Ralph Avenue
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1atOQklyn, N\ 11317 ,~ r
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R 3.W ps srtE . :'~tt i~. altdpA 9 sildlJ(ltion WDS phone number
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O St• t tlatid, Pa. 17 4 fli t1lt w 101W933
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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. C i )`, ( ?- A C T O R C E R T I F [ C '-. T I i 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.
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S Printed/Typed Name Title' Signature Date
P 10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No.
O IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 11215 JA-462
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Printed/fypedName Title Si nature j T Date M/D/Y
R 1 1. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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Printed/Typed Name Title Signature Date(M/D/Y)
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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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Printedlfyped Name
X k Title Signature
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Date (Mi )
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000128728
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