NYC 9/11 Public Portal Document
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IESI NY CORPORATION
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST 77
1 1 2 4 '1.. DATE 7 / 1 L.
1. Job Site Address Owner's name Wait and Load
15 Dutch Street Dept Of Ellvironzuentel Time In
New York, N.Y. P"roteChotI Time Out
2. C t is name ai4~a~dd s~ _ p Drop Date
~~ B:i m lAU1JrLpt $1 ~G
1249 Ralph Avenue
G &rookth, NY 11236
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R 3. `~ ~tion WDS phone number
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P.O. Box 399
o Seotland, Pa 17254 Peak # 10+0934
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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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S Piinted/TypedNaxne Tit a Signature Date (M/D -
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10. Transporter #1 (Ackrawledgemmt of receipt of materials) DEC Permit No.
R IESI NY CORPORATION • 110 5th Street, Brooklyn, NY 11215
_ JA-462
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PrintedtTyped Name
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Title Si tore Date (M/DIY)
11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
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Printed/Typed Name Title Signatu 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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Printed/Typed Name
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Title Signature Date(M/D/Y)
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000130809
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