Medical Waste Load Manifest Form
Generator Information
Facility Name
Address
City
State
ZIP Code
Contact Name
Phone Number
Waste Transporter Information
Company Name
Driver Name
License #
Vehicle ID/Plate #
Waste Description
Container Type
Number of Containers
Total Weight (lbs)
Description of Waste
Destination Facility
Facility Name
Address
City
State
ZIP Code
Signatures
Generator Signature
Transporter Signature
Recipient Signature
Date