HomeMy WebLinkAbout2018-08-07 Non-Hazardous Waste Manifest - Grease Interceptor - Walmart i
f
• t
■ ea ;
LIQUID ENVIRONMENTAL SOLUTIONS No. 4 7 6 3
i
ENVIRONMENTAL
SOLUTIONS NON-HAZARDOUS WASTE MANIFEST
•
• GENERATOR INFORMATION
Generator Name {(A e Celt- c f V Contact Name
Address ,91 j N9t el) A V€ Phone
City,State S,'C-\\ ,A.30,„),_`Qr1 ru'1 Zip 5-5-pia Profile# f
Customer# tg 21 f_5-q_oo
County
Type of Trap: Ls Grease Interceptor _Septic/Chemical Toilet _Gnt/Sand Trap _Special _Outside _Inside
Non-Industrial _Industrial Trap Condition: F
Tank#1Q
/716 gallons Tank#2 26- gallons Service Frequency Weeks 1
Tank#3 gallons Tank#4 !! gallons
i
Generator Certification: l 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, rt.
toxic substance,hazarrdous substance,solvent or oil as defined in or pursuant to the Resource Conservation and Recovery Act,the r
Comprehensive Environmental Response Compensation and Liability Act,the Federal Clean Water Act,or any other federal,state ii
ii
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 orp.
proper disposal of any hazardous waste and that the Generator expressly agrees to defend,indemnify and hold harmless the Transporter w'
from and against any and all damages,costs,fines and liabilities resulting from or arising out of any such hazardous waste.
Originator Name(NOinted) f 1 Signature /�-1- ate limeii
NO nm.-1-�'„ `„� fl t:7 re- la
Lrel
i
TRANSPORTER INFORM TION
Company Liquid Environmental Solutions Driver Name 9 1
Lififj h:
Address 9199 Davenport Street NE Phone 11 (763)784-6306
City,State Blaine, MN Zip 55449
State Registration# FOG Permit#
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. i.
Suver lame ennte• �j y' 1 ignature late ^tee l-awl
41 A
-4,..., 74 e
1 2 ;--‘ ,..
RECEIVER/DISPOSAL INFORMATION
Disposal Name Metro Liquid Waste Receiving Facility Contact NameiI
Address 2400 Childs,Road . Phone (651) 602-8393
City,State St. Paul, MN Zip 55106 County Ramsey
it
EPD Approval/Permit# NPDES# i LAS# '
•
Solid Waste Handling#' Industrial Pretreatment Permit#
Total Quantity Received Gallons j q
Certification of Receipt: The above waste was received by this facility within the property boundaries and will be processed,disposed ri
of,or recycled in accordance with all applicable laws.
Disposal Nameii
p (Printed) Signature Date Time
Ir
ii
WHITE-TRANSPORTER YELLOW-DISPOSAL SITE PINK-GENERATOR a
January 2012 re v.1 s
,