The purpose of this form is to track the grease that is removed from a user’s establishment. It is a standard form that helps all FSF’s record the volume of grease that is being pumped and removed from their facility. It also helps to ensure that the grease is disposed to a proper location.
INSTRUCTIONS TO USER REPRESENTATIVE: An authorized representative for the User shall fill out all information requested in the top box of the form. The business address shall be the physical address and not a post office box. The User representative shall sign and date the form when the waste is removed certifying that the waste being removed contains no hazardous material.**
INSTRUCTIONS TO WASTE HAULER: The driver of the service vehicle is considered an authorized representative for the waste hauler. The driver shall fill in requested information regarding the waste hauler in the second box of the manifest and shall complete the certification regarding the nature of the waste removed. The address shall be the mailing address of the waste hauler. The driver shall maintain possession of the manifest until the waste is discharged at a qualified disposal site. The waste hauler shall then give the form to the disposal site representative to complete.
INSTRUCTIONS TO DISPOSER: An authorized representative for the disposal facility shall fill in requested information in the bottom box of the manifest. The address shall be the mailing address of the disposal facility. The waste disposal site shall be the physical location of the disposal facility. Some examples of the waste disposal methods are landfill burial and wastewater treatment plant. The waste disposal method shall not be detailed. The disposing facility representative shall complete the certification and return the original manifest to the User listed in the first box of the form.
**THE FOOD SERVICE FACILITY SHALL KEEP A COPY OF THIS MANIFEST AFTER THE WASTE HAULER HAS ACCEPTED THE WASTE. THE USER SHALL ALSO PROVIDE A SELF-ADDRESSED, STAMPED ENVELOPE WITH THE ORIGINAL FORM TO ENSURE ITS RETURN AFTER THE WASTE HAS BEEN DELIVERED TO THE DISPOSAL SITE. IT IS THE USER’S RESPONSIBILITY TO TRACK THE MANIFEST AND TO MAINTAIN A COPY OF EACH COMPLETED MANIFEST AT THE USER’S ESTABLISHMENT.
CITY OF MT. VERNON, ILLINOIS |
WASTE HAULER MANIFEST |
EMERGENCY PHONE NUMBER (618)___________ |
GENERATOR INFORMATION |
Business Name: __________________________________________________________________________________ |
Address: ______________________________ City: __________________________ State: ________ Zip: ________ |
Phone: ________________________________________ Customer Billing: _________________________________ |
Waste tank or Trap Capacity: _______________________ gallons Pump Freq: ____________________________ |
Waste From: Grease Trap Grip Trap Other ________________________________________________ |
I CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE, THE WASTE MATERIAL REMOVED FROM THE ABOVE PREMISES CONTAINS NO HAZARDOUS MATERIAL. I ALSO CERTIFY THAT A REPRESENTATIVE OF THIS BUSINESS WITNESSED THE PUMPING OR INSPECTED THE TRAP AFTERWARDS. |
____________________________________ (Print Name) |
_________________ ____________________ _______________________________________ (Date) (Time In) (Signature) |
WASTE HAULER INFORMATION |
Business Name: ___________________________________________________________________________________ |
Address: ______________________________ City: __________________________ State: ________ Zip: ________ |
Phone: _____________________________________ Truck License Number: _______________________________ |
Gallons Received: ___________________________ Vehicle Permit Number: ______________________________ |
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS CORRECT AND THAT ONLY THE TYPE WASTE SPECIFIED IS CONTAINED IN THE SERVICING VEHICLE. |
____________________________________________ ______________________________________________ (Driver’s License No.) (Driver Name - Print) |
_________________ ________________ __________________________________________ (Date) (Time Out) (Signature) |
DISPOSAL INFORMATION |
Business Name: ___________________________________________________________________________________ |
Address: ______________________________ City: __________________________ State: ________ Zip: ________ |
Phone: ______________________________________ Gallons Received: ________________________________ |
I CERTIFY THAT I HAVE DISPOSED OF THE WASTE IN ACCORDANCE WITH ALL CITY, STATE AND FEDERAL LAWS. |
___________________________________________ _____________________________________________ (Date and Time Received) (Print Name) |
_____________________________________________ (Signature) |
(Prior Code, Art. 16A, App. B)