Environmental Hazardous Waste Export Manifest

Manifest Document Number

Date of Issue

Page Number

1. Generator/Exporter Information

Company Name

Address

City

State/Province

Postal Code

Country

Contact Name

Phone

Company Name

Address

City

State/Province

Postal Code

Country

Facility Name

Address

City

State/Province

Postal Code

Country

No.	Company Name	Address	Country	Contact Name	Phone
1
2

Line No.	Description of Waste	UN Number	Quantity	Unit	Packaging Type	Waste Code
1
2

Name

Signature

Date

No.	Name	Signature	Date
1
2

Name

Signature

Date