HomeMy WebLinkAbout2020-09-24 Liquid Environmental Solutions - Non-Hazardous Waste Manifest (Grease Interceptor) •
. LI I LI LIQUID ENVIRONMENTAL SOLUTIONS ,Nb. ±,49 . -
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_ 3N ON:cr: l NON-HAZARDOUS WASTE MANIFEST
GENERATOR INFORMATION •
Generator Name ? dent Z52red �C.,6/e6 Contact Name
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Address /353C �"d. 5t. /1'> Phone i
City, State(2:2"/ /7).„,,-k g25,, /Z Al Zip 530,5 Profile# )
Customer# .159'- 6.--/ ed 3f7 County
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Type of Trap: —Grease Intercepter _Septic/Chemical Toilet _Grit/Sand Trap _Special. Outside _Inside
_Non-Industrial _Industrial Trap Condition l
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Tank#1 gcso gallons Tank#2 gallons
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Tank#3 gallons Tank#4 gallons Service Frequency Weeks
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, ig
toxic substance,hazardous 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 r
or local environmental law,regulation,ordinance,or rule,whether existing as of the date of this agreement or subsequently enacted. r'
I also acknowledge that the Generator shall be responsible for any costs incurred by the Transporter or Disposal FaaTrty 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 all damages,costs,fines and liabilities resulting from or arising out of any such hazardous waste. i.
!Originator Name(printed) Signature Date Time 1
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TRANSPORTER INFORMATION C
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Company Liquid Environmental Solutions Driver Name
Address 9199 Davenport Street NE Phone (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.
Driver Name(printed) Signatu Date Time
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RECEIVER/DISPOSAL INFORMATION
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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
=PD Approval/Permit# NPDES# LAS#
Solid Waste Handling# Industrial Pretreatment Permit#
Total Quantity Received Gallons goo
Certification of Receipt: The above waste was received by this facility within the property boundaries and will be processed,
disposed of,or recycled in accordance with all applicable laws.
i !Disposal Name (printed) Signature Date Time
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WHITE-TRANSPORTER YELLOW.-DISPOSAL SITE PINK-GENERATOR