Biomedical Waste Manifest Document

Manifest Number:
Date:
1. Generator Information
Facility Name:
Address:
Contact Person:
Phone:
2. Transporter Information
Company Name:
Address:
Contact Person:
Phone:
Vehicle Number:
Transport Date:
3. Waste Description
Waste Category Number of Containers/Bags Quantity (kg) Container Type
4. Receiver Information
Facility Name:
Address:
Contact Person:
Phone:
5. Generator Certification
I hereby certify that the information above is true and that the described waste has been packaged and labeled in accordance with applicable regulations.
Name: Signature: Date:
6. Transporter Acknowledgement
Name: Signature: Date:
7. Receiver Certification
I hereby confirm receipt of the above biomedical waste for safe treatment/disposal.
Name: Signature: Date: