NYC 9/11 Public Portal Document
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IESI NY COI ,g;TION
110 5th Street •Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697 ----T
MANIFEST / /.S
1 1112 DATE 1
1. Job Site Address Owner's name Wait and Load
7 loch S1reStreet Dept of Environmeotal Time In
N YNeWYe1t,N.Y. Proted14l1 Time Out
2. Cr rg grs naar~+e akW s & Drop Date
124k Ralph Avenue
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Prooklya,NY 11236
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R 3_ ~~tion WDS phone number
A P.O_ Sox 399
o SScotland, Pa 17254 Peel # 10b934
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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. Descriptionofmaterials
6.VEH. LIC. # 7. TOTAL QUANTITY
(RQ) WASTE ASBESTOS 9, NA2212, III TYPE ' BAGS
SIZE Z. 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 y propershi ing name and are classified, packed, marked and labeled, and are in all respects in proper condition for transport by
A highw ac26rn applicable international government regulations.
N
S Printed/Typed Name Title Signature Date (M/D r
P 10. Transporter #1 (Aelmowledg•ment of remipt of materials)
O DEC Petmit No.
R IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 1215 JA-462
E Printed/rypedName Title Signature Date MID
R 11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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A ^+1
IS Printedlr erne Title Si ture Date )/ •
E 12. Discrepancy indication space
S ~ -
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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
E
Printed/Typed Name litIe ignature Date ( .1
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000130761
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