HomeMy WebLinkAbout2019-09-16 Non-Hazardous Waste Manifest - Grease Interceptor - Walmart LIQUID ENVIRONMENTAL SOLUTIONS No. 5 6 4 4
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ENVIRONMENTAL -
SOLUTIONS NON-HAZARDOUS WASTE MANIFEST
GENERATOR INFORMATION
GeneratorName Si t #'; 4 /IA-73c, I Contact Name
Address 11 � ��� - i9v.� Phone
city,Slate OA L f57Aff fie.wey.v,r ZIP -576C1 #
Customer# l2 t(0 —006 County
Type of Trap: ZiGrease Intercepter _Septic/Chemical Toiet _Gni/Sand Trap _Special —Outside _inside
_Non-Industrial industrial Trap Condition:
- Tank#1 Q gallons Tank#2 61,CC 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 of 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 rile,whether existing as of the date of this agreement or subsequently enacted.
L I also acknowledge that the Generator shall be responsible for any costs incurred by the Transporter or Disposal Featly 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 ai damages,costs,fines and liabFlies resuting from or-arising out of any such hazardous waste.
r Originator Mame i Signalise Dade Time
TRANSPORTER INFORMATION
Company Liquid Environmental Solutions Driver Mame j//
Address 9199 Davenport Street NE Phone (763)784-6306
City,State Blaine, MN zip 55449
• • State Registration# FOG Permit#
Transporter Certification: Icertify that the irdon mtkin 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.
• Dever Name 17 _ Watore Date • Time
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RECEIVER/DISPOSAL INFORMATION
Disposal Name Metro Liquid Waste Receiving Facility Contact Name
. Address 2400 Childs Road Phone (651)602-8393
City,&Ate St. Paul, MN • zip 55106 County Ramsey
EPD ApprovaUPerrnit# NPDES# _ LAS#
Solid Waste Handling# Industrial Pretreatment Permit*
Total Quantity Received Gallons 17 •
Certification of Receipt The above waste was received by this facility want the.propeity boundaries and will be proms,disposed
of,or recycled in accordance with al applicable laws.
- Disposal Name(Printed) Dale Time
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WHITE-TRANSPORTER YELLOW-DISPOSAL s1TE WIpC-GENERATOR
Ja uary 2012 rev.1