HomeMy WebLinkAbout2019-06-19 Non-Hazardous Waste Manifest - Grease Interceptor - Walmart I ` 4 LIQUID ENVIRONMENTAL SOLUTIONS No. 5 r -` 7
• i 1 I
ENVIRONMENTAL
SOLUTIONS NON-HAZARDOUS WASTE MANIFEST
GENERATOR INFORMATION 1
Generator Name I. t,IC �7 / / Contact Name s
j Y
Address r(547,f—
_ ///c/Z/.-.-44 6/e Phone
City,State C, /rpfix/r 7.�/ev;,7 J Zip 1-10 Y,? Profile#
Customer# %Z L//f C7 'VciC7C Z, County
Type of Trap: LLGrease Interceptor _Septic/Chemical Toilet _Grit/Sand Trap _Special _Outside ,Inside
_Non-Industrial _Industrial Trap Condition:
Tank#1 ,►8 G O gallons Tank#2 -7CQ 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, g
explosive,toxic or hazardous material("Excluded Waste"). The term"hazardous material"is defined as any one or more pollutant, i
toxic substance,hazarrdous substance,solvent or oil as defined in or pursuant to the Resource Conservation and Recovery Act,the i
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 U
proper disposal of any hazardous waste and that the Generator expressly agrees to defend,indemnify and hold harmless the Transporter
9
from and against any and all damages,costs,fines and liabilities resulting from or arising out of any such hazardous waste.
Originator Name(Printed) Signature Date Time
r
r:
ri
TRANSPORTER INFORMATION
Company Liquid Environmental Solutions Driver Name Cif
Address 9199 Davenport Street NE Phone (763) 784-6306 5
City,State Blaine, MN Zip 55449 j
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.
•
IP er lame "nntee SignatureG' Date Time
, ------- G-/9-7r ,
RECEIVERIDISPOSAL INFORMATION 3.
Disposal Name Metro Liquid Waste Receiving Facility Contact Name '`
If
Address 2400 Childs Road Phone (651) 602-8393
City,State St. Paul, MN Zip 55106 county Ramsey !'t
EPD Approval/Permit# NPDES# LAS# il
Solid Waste Handling# Industrial Pretreatment Permit#
Total Quantity Received Gallons 2 .5-0 ofr
I
Certification of Receipt: The above waste was received by this facility within the property boundaries and will be processed,disposed
ot,or recycled in accordance with all applicable laws. E
Disposal Name(Printed) Signature Date Time 1
f
WHITE-TRANSPORTER YELLOW-DISPOSAL SITE PINK-GENERATOR i
ii
January 2012 rev.1
i