NYC 9/11 Public Portal Document
IESI N , RPORATION
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST
11778 DATE 1310
1. DpfsOfe Wait and Load
,hateclil4
llt fall,N.Y. Time In
• Time Out
I
2. C Drop Date
d d
Brooklyn. NY 11236
G
E
E IFS Pt Bye Ridge Ladfihl Co ions
R 3. name,mailing address and physical site location WDS phone number
T
5cotl>ee4, Pa, 172M Pelr>ln>l~ #100934
0
R
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. #
mI 4 7. TOTAL QUANTITY
(RQ) WASTE ASBESTOS 9, NA2212, III TYPE ' BAGS
SIZE • D 3 CUBICYARDS
8. GeneratorCertification ,
iG.
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 conditio for transport by
A highway according to applicable international government regulations.
S Printed/Typed Name Title Signature Date M/D/Y
P
10. Transporter #1 (Acknowledgement of receipt of, materials) DEC Permit No.
O IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 15 1 y.e, JA_ 2
R
T DRIVER 't
E riot Name 'Title i s 1 Date M/
R
11. Transporter #2 (Acknowledgement of receipt of materials) . DEC PERMIT #
W
A
T Printed/Typed Name Title Sigla e Date IV)
E 12. Discrepancy indication space
S
1
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
Printed/Typed Name • Title. Signature Date (MID/Y)
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR •YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000128729
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