HomeMy WebLinkAbout2025-08-12 Liquid Environmental Solutions - Non-Hazardous Waste Manifest (Grease Interceptor)Originator
PANERA BREAD #606100
Signature Date
08/12/2025
Time
01:06:51 PM
Manifest # 25082102491
LIQUID ENVIRONMENTAL SOLUTIONS
NON-HAZARDOUS WASTE MANIFEST
Name
PANERA BREAD #606100
Contact Name
Address
13535 60TH ST N
Phone
City, State
OAK PARK HEIGHTS, MN
Zip
55082
County
Customer #
42745100319
Profile #
N/A
Service Frequency
8
Service Completion Date
08/12/2025 07:32:31 AM
Tank #1 (gallons)
800
Tank #1 (Top Grease)
2
Tank #1 (Middle Water)
40
Tank #1 (Bottom Sludge)
6
Company
Liquid Environmental Solutions
Driver Name
BRIAN CARLBOM
Address
9199 DAVENPORT ST
Phone
866-694-7327
City, State
BLAINE, MN
Zip
55449
State Registration #
Driver Name
BRIAN CARLBOM
Signature Date
08/12/2025
Time
01:05:53 PM
Disposal Name
METROPOLITAN SEWER-MN
Contact Name
Address
2400 CHILDS RD
Phone
City, State
SAINT PAUL, MN
Zip
55106
County
Facility Representative
METROPOLITAN SEWER-MN
Signature Date
08/12/2025
Time
01:05:48 PM
Route #/CDFA Manifest #
01MING
Total Quantity Recieved Gallons
800
Generator Certification: I certify the waste material removed from the above premises does not contain any radioative, flammable, explosive, toxic or hazardous material ("Excluded Waste"). The
term "hazardous","materials" is defined as 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 Act, or any other federal state or local envirnmental law, regulation, ordinance, or rule, whether
existing as of the date of this agreement or subsequently enacted. I also acknowlege 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 arising out of any such hazardous waste.
TRANSPORTER INFORMATION
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
falsifcation of this manifest may result in procesuction.
RECEIVER/DISPOSAL INFORMATION
Certification of Receipt: The above waste was received by the facility within the property boundaries and will be processed, disposed of, or recycled in accordance with all applicable laws.