Agricultural Pesticide Waste Manifest
1. Generator Information
Generator Name/Company
Site Address
Contact Person
Phone
Email
2. Transporter Information
Transporter Name
Vehicle/License Number
Contact
3. Disposal Facility Information
Facility Name
Facility Address
Contact
4. Waste Description
Pesticide Name
EPA Reg. No.
Container Type/Size
Quantity
Physical State
Comments
5. Signatures
Generator Signature
Date
Transporter Signature
Date
Facility Signature
Date