NYC 9/11 Public Portal Document
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IESI NY COR. l TION
110 5th Street • Brooklyn, NY 11215
Phone: 718-522-2263 • Fax: 718-522-2697
MANIFEST f
DATE
1. Job Site Address Owner's name Wait and Load
15 Strew
`Dutch Dept of EDE~'obb welt l Time In
N I f New York, 1' -Y - Pr ot ec ti~ Time Out
2. C~ra~tgry ~r @/pgaet#add~re8 Drop Date
& Son
124k8RalphAti
2 Ralph Av rue
EG Brtaoklpn, NY 11236
N
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R 3, wlL&L WDS phone number
A P.O. Box 399
T
O Scotland, Pa.17234 Pe!mit # 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. Descriptionofmaterials
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 abo a by proper shipping name and are classified, packed, marked and labeled, and are in all respects in proper condition for transport by
A highway o g to plicable international government regulations.
N ~
S Print ypeci Name Title Signature Date (M/D "1
P
10. Transporter #1 (Acknowledgement of receipt of materials) DEC Permit No.
0
R IESI NY CORPORATION • 110 5th Street, Brooklyn, NY) 15 JA-462
E Printed/ryped Name Title Signature TT J Date M/D/Y q °e
R
11. Transporter #2 (Acknowledgement of receipt of materials) DEC PERMIT #
W
T
E
•
PrinteUTyped Name
12. Discrepancy indication space
Title Si atu
"-
Date /DIY `
S
I
T 13. Waste disposal site owner or operator: Certification of receipt of asbestos materials covered by this manifest except as noted in item #12
nted/1'yped Name Title
t+l.Laq AC[.
Signature
?YL Date (M/DIY
WHITE:LANDFILL • GREEN:IESI • PINK:GENERATOR • YELLOW:CONTRACTOR • GOLD:JOB SITE
NYC-WTC 000130810
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