HomeMy WebLinkAbout2017-08-17 Liquid Environmental Solution Non-Hazardous Waste Manifest - Grease Interceptor Imo:_
LIQUID ENVIRONMENTAL SOLUTIONS No. 3 3 2 9
ENVIRONMENTAL
SOLUTIONS NON-HAZARDOUS WASTE MANIFEST
GENERATOR INFORMATION
II
Generator Name / co Rc..// /S 7 4 3 Contact Name
Address i yrs a5 6,04-), S91 A) Phone (CIS/) y3 6— 3117&5
City,State S .-s, //(,a4?tee, M ) Zip Ss0g Profile#
Customer# 50 t/aPS— - GOo 3s—
County (,,JeiSir:"IA fz)H
Type of Trap: LGrease Interceptor __Septic/Chemical Toilet _Grit/Sand Trap _Special _Outside X Inside
_Non-Industrial _Industrial Trap Condition:
Tank#1 076 gallons Tank#2 gallons Service Frequency Weeks
Tank#3 gallons Tank#4 gallons
Generator Certification: I certify that the waste material removed from the above premises does not contain any radioactive,flammable,
explosive,toxic or hazardous material("Excluded Waste"). The term"hazardous material"is defined as any one or more pollutant,
toxic substance,hazarrdous substance,solvent or oil as defined in or pursuant to the Resource Conservation and Recovery Act,the
Comprehensive Environmental Response Compensation and Liability Act,the Federal Clean Water Act,or any other federal,state
or local environmental law,regulation,ordinance,or rule,whether existing as of the date of this agreement or subsequently enacted.
I also acknowledge that the Generator shall be responsible for any costs incurred by the Transporter or Disposal Facility in handling or
proper disposal of any hazardous waste and that the Generator expressly agrees to defend,indemnify and hold harmless the Transporter
from and against any and all damages,costs,fines and liabilities resulting from or arising out of any such hazardous waste.
Oriu inator Name(Printed) Signature Date Time
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T'+' 'SPORTER I MATION �--._
Company Liquid Environmental Solutions Driver Name 1 '
Address 9199 Davenport Street NE Phone (763) 784-6306
City,State Blaine, MN Zip 55449
State Registration# FOG Permit#
T •• •er Certification: I certify that th- • ation above is accurate,and that only the waste certified for removal by the Generator
is contai .d in the servicing vehicle. I a .ware t at faisificatio f is manifest may result in prosecution.
Driver .me(Prin-d) Sign. re .Dat Time
1.94:1 /7 . IN ID ( 8 12_
REC:IVER/DISPOSAL INFORMATION
I isposal Name Metro Liquid Was e Receiving Facility Contact Name
'ddress 2400 Childs Road Phone (651) 602-8393
City,State St. Paul, MN Zip 55106 County Ramsey
EPD Approval/Permit# NPDES# LAS#
Solid Waste Handling# Industrial Pretreatment Permit#
Total Quantity Received Gallons 2
Certification of Receipt: The above waste was received by this facility within the property boundaries and will be processed,disposed
of,or recycled in accordance with all applicable laws.
Disposal Name(Printed) Signature _ Date lime
Sic lla-�C in•-e 41104-41104- Oder: 6. a/-—
WHITE-TRANSPORTER YELLOW-DISPOSAL SITE PINK-GENERATOR
January 2012 rev.1