HomeMy WebLinkAbout2017-05-22 Liquid Environmental Solutions - Non Hazardous Waste Manifest4W -
ENVIRONMENTAL
SOLUTIONS
LIQUID ENVIRONMENTAL SOLUTIONS No. 3128
NON -HAZARDOUS WASTE MANIFEST
GENERATOR INFO
Generator Name St4 ptdCrr Awor
Address ,� 1 S /Votell 40c
C' St t
Contact Name
Phone ii !oS I� H 3 5 _ 7b 7
Ity, a e Sf, J 4, 04" fe,•, W!W Zip SSo & 9 Profile #
Customer # r.Ja y/ S 7 000&;L
T
County Ijd,slr". fo>K
Type of Trap. 4%Grease Interceptor _ Septic/Chemical Toilet _ Grit/Sand Trap
_ Non -Industrial _ Industrial Trap Condition:
_Special 5e Outside _ Inside
Tank #1 033 gallons Tank #2 O� 3 gallons Service Frequency 1 at 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 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 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.
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TRANSPORTER INFORMATION ('
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 awa that falsification of this manifest may result in prosecution.
R
U Time
RCEIVER/DISPOSAL INFORMATION
Disposal Name Metro Liquid ste Receiving Facility Contact Name
Address 2400 Childs Road Phone
City, State St. Paul, MN zip 55106 County
EPD Approval/Permit # NPDES #
Solid Waste Handling # Industrial Pretreatment Permit #
(651) 602-8393
Ramsey
LAS #
Total Quantity Received Gallons —99 -7
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.
Disposal Name(Printed) Signature ate Time
Sts 4-1 -c
WHITE - TRANSPORTER YELLOW - DISPOSAL SITE PINK -
January 2012 rev.1
Work Completion Form
Is the customer available? Is the customer able to inspect?
Customer Questionnaire
Have you inspected the work?
Were safety cones used?
Is the area around the trap clean?
Are trap lids secured and closed?
Was disruption to business minimized?
Did we meet your expectation?
Customer Signature
Customer Printed Name
Customer Title
FST ROBERT SCOTT