HomeMy WebLinkAbout2022-12-14 Liquid Environmental Solutions - Non-Hazardous Waste Manifest (Grease Interceptor) Route/SC ID
221021-0288 ti '' LIQUID ENVIRONMENTAL SOLUTIONS No. 7 3 4 9
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ENVIRONMENTAL
SOLUTIONS NON-HAZARDOUS WASTE MANIFEST
GENERATOR INFORMATION
Generator Name
i_.,) - -♦ 0 j Contact Name
Address /• 3 ' 6 o S ti Phone
City,State
..c - 4 Zip,$-a) Profile#
Customer# y2. 7W-7"—COS/9 County
Type of Trap: Z-Grease Interceptor _Septic/Chemical Toilet _Grit/Sand Trap _Special XOutside _Inside
_Non-Industrial _Industrial Trap Condition:
Tank#1 roe 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 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,ordinanqe,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.
Originator Name(Printed) Signature Date Time
TRANSPORTER INFORMATION
Company Liquid Environmental Solutions Driver Name
Address 9199 Davenport Stre0 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 manitest may result in prosecution.
Inver lame •ante/ ignature late ime
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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,State St. Paul, MN Zip 55106 county Ramsey
EPD Approval/Permit# NPDES# LAS#
Solid Waste Handling# Industrial Pretreatment Permit#
Total Quantity Received Gallons
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 Date Time
WHITE-TRANSPORTER YELLOW-DISPOSAL SITE PINK-GENERATOR
January 2012 rev.1