HomeMy WebLinkAbout2023-06-14 Liquid Environmental Solutions - Non-Hazardous Waste Manifest (Grease Interceptor) Route/SC ID
230613-0369
"` LIQUID ENVIRONMENTAL SOLUTIONS No. 7639
' ENVIRONMENTAL
SOLUTIONS NON-HAZARDOUS WASTE MANIFEST
GENERATOR INFORMATION
Generator Name �a� ra Frea el Contact Name
Address 1353.5 s4 Phone
City,State CA\( `?Ar IRK) Zip 5503Z. Profile#
Customer# ga7gS 16(}/31C County
Type of Trap: riGrease Interceptor Septic/Chemical Toilet _Grit/Sand Trap _Special Outside _Inside
Non-Industrial _Industrial Trap Condition:
Tank#1 R&3 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,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.
Originator Name(Printed) Signature Date Time
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 am aware that falsification of this manifest may result in prosecution.
Driver Name(Printed) Signatu Date Time
emv� . 3t - 14-e..3
RECEIVERIDISPOSAL 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
Manifest#23061303691
ENVIR ON ME NSAI
S O S°'I a N S LIQUID ENVIRONMENTAL SOLUTIONS
Cleon.Reliable.Innovoli...
NON-HAZARDOUS WASTEMANIHSST
None Conran Name
PANERA BREAD#606100
Address Phone
13535 60T11 STN 6513239021
City,State Zip County
OAK PARK HEIGHTS,MN 55082
Custom# Pmfle#
42745100319 #N/A
Tank#1(gallons) Tails#2(gallons) Service Frequency
800 0 8
Tank#3(gallons) Tank#4(gallons)
0 0
Generator Certification:I certify the waste material removed torn the above premises does not contain any radioative,laminable,explosive,toxic or hazardous material("Excluded Waste").The
term"hazardous","materials"is defned m any one or more pollutant,toxic substance,hazardous substance,solvent or oil as defined in or pursuant to the Resource Conservation and Recovery Act,
the Comprehensive Environment Response Compensation and Liability Act,the Federal Clean Water Ad,or any other Wend state or local envimmental law,regulation,ordinance,or rule,whether
existing as ofthe date of this agreement or subsequently enacted.1 also axfmowlege that the Generator shall he responsible fir any costs inhere by the Transporter or Disposal.Facility in handling or
proper disposal of any hazardous waste and that the Generator expressly agrees to defend,indennit and hold harmless the Transporter four and against any and all damages,costs,foes and liabilities
resulting Porn arising out of my such hazardous waste.
Originator Signature Date Time
PANERA BREAD#606100 06/14/2023 01:0325 PM
TRANSPORTER INFORMATION
Company Driver Name
Liquid Enviiofnit tat Solutions KIERON BRISTER
Address Phone
9199 DAVENPORT ST
City,State Tap State Registration#
BLAINE,MN 55449
Transporter Certification:I certify that the information above is accurate,and that only the waste certifed fix removal by the generator is contained in the servicing vehicle l an aware that
filsifation ofthis manifest may result in promuction.
Driver Name Signature Date Time
KIERON BRIS l 06/14/2023 01:0320 PM
RECEIVER/DISPOSAL INFORMATION
Disposal Name Contact Name
METRO LIQUID WASTE
Address Phone
2400 CHI DS RD
City,State Zip County
SAINT PAUL,MN 55106
Route#/CDFA Manifest# 'Total Quantity Recieved Gallons
01KB 800
Certification of Receipt:The above waste was received by the 5eility within the property boundaries and will be processed,disposed of or recycled in accordance with all applicable laws.
Facility Representative Signature Date Time
METRO LIQUID WASTE 06/14/2023 01:03:15 PM