180 Waste Manifest 2015 IVIRONMENTAI.
SOLUTIONS
LIQUID ENVIRONMENTAL SOLUTIONS
No. 000834
NON-HAZARDOUS WASTE MANIFEST
GENERATOR INFORMATION
Generator Name DM5to k) I v--431 0 1 Contact Name
Address J y�6 t komee, S 1 Phone
City,State 14 d fun,-}tvvs,-t ria IJ l41►� Zip � 10 (aO Profile#
Customer# O ?-Z 3 —A q d
County
Type of Trap: *Greae Interceptor _Septic/Chemlcal Toilet _Grit/Sand Trap _Special _Outside _Inside
_Non-Industrial Industrial Trap Condition:
Tank#1
Tank#3
970
gallons Tank#2 gallons Service Frequency Weeks
gallons Tank#4 gallons
terator Certification:Customer warrants that food waste or wastewater collected by Contractor will not contain any radioactive,flammable,explosive,chemical,toxic or
srdous material("Excluded Waste").The term"hazardous material"means any one or more pollutant,toxic substance,hazardous waste,hazardous material,hazardous
stance,solvent or oil as defined in or pursuant to the Resource Conservation and Recovery Act,as amended,the Comprehensive Environmental Response,Compensation and
ility Act,as amended,the Federal Clean Water Act,as amended,or any other Federal,Statear local environmental law,regulation,ordinance,or rule,whether existing as of
date of this Agreement or subsequently enacted.in addition,Customer acknowledges that their waste materials may be suitable for energy and nutrient recovery through
erobic digestion or other recycling applications and therefore agrees to exclude contaminants to these recycling programs from their waste materials.Contaminants are
ned as,but not limited to:septage,septic holding tank wastes,sewage,or sludge;industrial wastes;and more than incidental volumes of inerts,such as silverware,plastics,
other garbage.For purposes of organics recycling,only food scraps and food production wastes maybe Included.Contractor shall acquire title to the Waste Material after It is
led into Contractor's collection vehicle;provided,however,title to and liability for Excluded Waste shall remain with Customer at all times.Customer shall be responsible for
costs incurred by Contractor in the handling or proper disposal of any Excluded Waste and Customer expressly agrees to defend,indemnify and hold harmless Contractor from
against any and all damages,costs,losses,penalties,fines and liabilities resulting from or arising out of any such Excluded Waste.
Originator Name(Printed)
Signature
ANSPORTER INFORMATION
Company Liquid Environmental Solutions Driver Name
Address 527 Pleasant Street
City,State Attleboro, MA
State Registration# N/A
Zip
02703
Date
Time
Phone 508-236-6001
FOG Permit# NIA
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 falsifi ;;; of this manifest may result in prosecution.
ame(-nnte.l igna ure
/2 L
Disposal Name
a e ime
31- 7G'
REC:` ER/DISPOSAL INFORMATION
A Green Energy Contact Name
Phone 914-924-3195
Address 51 Muschopauge RD
City,State Rutland, MA
EPD ApprovaliPermit#
Solid Waste Handling#
Zip
NPDES#
Industrial Pretreatment Permit#
Shannon Carroll
County
LAS#
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(Pnnted) Signature Date Time
WHITE-TRANSPORTER
YELLOW-DISPOSAL SITE
PINK-GENERATOR
January 2012 rev.1