NYC 9/11 Public Portal Document
NYDEC 1A-371 NYDCA 483856
o
• begto8 C~?/rans orith tion
L.
P.O. BOX 1014 TOLL Fli t PHONE 831-924.5050
HAMPTON BAYS, N.Y. 11946 1.800-755-OATC FAX 631-924-5085
"EMERGENCY NUMBER"
Waste Manifest # Jobs Floor or Location Cust #
2O/ c179 umber
318
1. Work ito Name and ailing Address er s Name. Address, Phone
PROPERTIES
115 BROADWAY 115 BROADWAY
o oJs &A ess as DL2&&te
SOUTHERN ALLEG1iENI1~8 DISPOSAL SVCS.
COMPLETE ENVIRONMENTAL SERVICES RD 3 BOX 310 VALLEYVIEW DRIVE
3500—A HAMPTON RD. HOLLSOPPLE, PA 15935
OCEANSIDE NEW YOUR 1i572 Other 0
Name and Address'of Responsible NESHAPS Agency
U.S. EPA REGION II, 290 BROADWAY, NEW YORK, NY 10007
Description of Materials E"s - Cub Ydg -
RQ Waste Asbestos, Class 9, NA2212, PGIII 0 Other Drums or Tons -OTHER-~
•
dl RQ Waste White Asbestos, Class 9, UN2590, PGIII
Special Handling Instructions and Additional Information
OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper
shipping name and are classified, packed, marked and labeled and are in all respects in proper condition for transport by highway according to
applicable International government regulations.
rv •v ? X
PtlnteFTyped Name V Title Signature Date (M/DD"
Transporter I (Acknowledgement of Receipt of Materials)
Telephone No.
Company Name and Address Si slurs: 631-924-5050
ASBESTOS TRANSPORTATION CO., INC.
P.O. BOX 1044 Printed Na e: Date
HAMPTON BAYS, NY 11946
Title. IVC
Transporter 2 (Acknowledgement of Receipt of Materials)
Telephone No.
Company Name and Address Signtmirw: _ 631.924-5050
ASBESTOS TRANSPORTATION CO., INC.
P.O. BOX 1044 Printed Name: Date
HAMPTON BAYS, NY 11946
Title: DRIVER
Discrepancy indication Space:
Woato Otspooal Site Owner or Operator'o•Cortiflcation (Receipt of Above Wa Aacoptad
1, 4 Telephone No.
tl B A~N1XS DISP, SVCS signature:
(814) 479-2983 Printed Name: /7 Date
Title;
~C -~7[t~!
0
g•d 106L99L919 03WOO eLTtII 20 12 qad
NYC-WTC 000132685
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