HomeMy WebLinkAbout2019-08-15 Liquid Environmental Solution Non-Hazardous Waste Manifest - Grease Interceptor LIQUID ENVIRONMENTAL SOLUTIONS No. 5 3 7 0
ENVIRONMENTAL
SOLUTIONS NON-HAZARDOUS WASTE MANIFEST
GENERATOR INFORMATION._
Generator Name ``-�
�C� 77 c /' '"" fc Contact Name
Address / 1;�� (-G 7-', 7 Phone
City,State r;/I-%/,is4P/� /..z(_;-./7;,-.5-- Zip ..5 ofile#
Customer# cf:cc`' Zr=- c i 3 f-- County
Type of Trap: ZGrease Interceptor _Septic,/Chemical Toilet _Grit/Sand Trap _Special _Outside _Inside •
_Non-Industrial _Industrial Trap Condition:
Tank#1 /G 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 rnateriar 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,taste and that the Generator expressly agrees to defend,indemnify and hold harmless the Transporter
from and against any and all damages,costs,fines aQi liabilities epulting from or arising out of any such hazardous waste.
Originator Name(Printed) Snit; i
Lfif t g 1Date lime
..,
1 -3-ic-vtn.
TR 'SPORTER INFORMATION
Company Liquid Environmental Solutions Driver Name (•(_—
Address 9199 Davenport Street NE Phone (763)784-6306
City,State Blaine, MN Zp 55449
State Registration# FOG Permit#
- Transporter Certification: I cerin that the info:ma:ion 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 man iest may result in prosecution.
-Driv/er Name(Printed) �j' /Signature DateTimeTime
if
RECEIVER/DISPOSAL INFORMATION
Disposal Name Metro Liquid Waste Receiving Facility Contact Name
•
Address 2400 Childs Road Phone (651) 602-8393
City, State St. Paul, MN Zap 55106 County Ramsey
EPD ApprovaVPermit# NPDES# LAS#
Solid Waste Handling# - Industrial Pretreatment Permit#
v
Total Quantity Received Gallons j0
I Certification of Receipt The above waste wc.=received bythis facilitywithin the property p party boundaries and will be processed,disposed
of,or recycled in accordance with all applicable lass.
Disposal Name(Printed) Signature Date Time
•
WHITE-TRANSPORTER YELLOW-DISPOSAL SITE PINK-GENERATOR
January 2012 rev.1
.
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