NYC 9/11 Public Portal Document
IESI NY CORPORATION
110 5th Street • Brooklyn, NY 11215
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Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST /s
11240 DATE 70 / ?-
1. Job Site Address Owner's name Wait and Load ~.
7 Dutch Suet Dept Of FzMro*lmeital Time In
New York.. N. Y. Protection Time Out
2. Cppgqtractor's name qpQ address & Drop Date
d3enJaiiIn l 6iljjZIPUQ Son
1248 R.lph venue
E Brooklyn, Imo' 11236
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R 3. ,-m 'li lt a i ah jttion WDS phone number
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O Scotland, Pa. 17254 Permit # 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.
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Printed/Typed Name Titfe Signature Date M/D s
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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 1J,215 JA-462
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E Printed/iypedName Title Signature Date (M/D/Y)
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11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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Printedlfyped Name
12. Discrepancy indication space
Title }_` Si atu Date (M/D/Y)
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T 13. Waste disposal site owner or oppla1r: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
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Printed/Typed Name
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Title
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Signature
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Date (M/D
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WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
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NYC-WTC 000130760
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