HomeMy WebLinkAbout2018-11-16 Liquid Environmental Solution Non-Hazardous Waste Manifest - Grease Interceptor r
i
a71
LIQUID ENVIRONMENTAL SOLUTIONS No. 51 19
ENVIRONMENTAL
SOLUTIONS NON-HAZARDOUS WASTE MANIFEST
GENERATOR INFORMATION
Generator Name CO Bp,0 1 7 1,1, Contact Name
Address I q c2 q i,, '47Phone
City,State '--In1 ) 1,,z, Zip r}5-o rofile#
Customer# .-elf,2 —000:36. County
Type of Trap: ZiGrease Interceptor ,Septic/Chemical Toilet __Grit/Sand Trap Special _Outside _Inside
Non-industrial _Industrial Trap Condition: t
Tank#1 gallons Tank#2 gallons Service Frequency Weeks L
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 materia('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. ir
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 ail damages,costs,fines and liabilities resulting from or arising out of any such hazardous waste.
Name(Printed) Signaler Date I I Time
j...„.„..._j.cc._ F<1, ,-,._.,.....1 ( Y(61 R ., 3q ,
:,
TRANSPOR ER ORMATION
Company Liquid Environmental Solutions Driver Name A 5
Address 9199 Davenport Street NE Phone 80jii.,0 784-6306 -
City,State Blaine, MN zip 55449 G.
F.
State Registration# FOG Permit# t
1
Transporter Certification: I certify that the information above is accurate,and that only the waste certified for removal by the Generator
is contained in the servicing vehicle. I am aware that falsification of this manifest may result in prosecution. K
Driveñc1f1f7&/UI7)
e ' ted) gnature Date Time
Driver
Ir-16-1g t 7, ...
RECEIVER/DISPOSAL INFORMATION I I
Disposal Name Metro Liquid Waste Receiving Facility Contact Name -{
Address 2400 Childs Road Phone (651)602.8393
city,State St. Paul, MN Zip 55106 county Ramsey
EPD Approval/Permit# NPDES# LAS# •: II
Solid Waste Handling# Industrial Pretreatment Permit#
Total Quantity Received Gallons )O ,
II
Certification of Receipt: The above waste was received by this facility within the property boundaries and will be processed,disposed I`
of,or recycled in accordance with all applicable laws. E
Lposal Name(Printed) Signature Date Time i?
is
WHITE•TRANSPORTER YELLOW-DISPOSAL SITE PINK-GENERATOR '•
January 2012 rev.
l
1