Form 13-hazardous Waste Manifest 3e3t12

Form 13 Hazardous waste manifest 1

Occupier’s Name & Mailing Address (including phone No.)

:

2 3 4

Occupier’s Registration No. : Manifest Document No. : Transporter’s Name & Address (including phone No. :

5 6 7 8

Type of Vehicle : Transporter’s Registration No. : Vehicle Registration No. : Designated Facility Name & Site Address : Facility ‘s Registration No : Facility’s phone No . : Waste Description : Total Quantity : Consistency : Transport Description of Wastes : Containers :

9 10 11 12 13 14 15

16 17 18 19 20

Total Quantity : Unit Wt / Vol. : Waste Category Number : Special Handling Instructions & Additional Information : OCCUPIER’S CERTIFICATE :

Typed Name& Stamp: Signature 21

22 23

:

Transporter Acknowledgement of receipt of wastes : Typed Name & Stamp: Signature : Discrepancy Note Space Facility Owner or Operator’s Certification of Receipt of Hazardous waste Typed Name & Stamp Signature :

(Truck/ Tanker/ Special Vehicle)

…………………m3 or MT

Number

Type

…………………..m3or MT …………………..m30r MT

I hereby declare that the contents of the consignment are fully and accurately described ,above by proper shipping name and are categorized , packed, marked, and labeled , and are in all respects in proper condition for transport by road according to applicable national government regulations. Month Day Year

Month

Month

Day

Day

Year

Year