Hazardous Materials Manifest

Generator Information

Company Name

Address

City

State

ZIP Code

EPA ID Number

Transporter Information

Transporter Name

EPA ID Number

Designated Facility Information

Facility Name

Address

City

State

ZIP Code

EPA ID Number

Waste Description

Container Number	Hazardous Material Description	Quantity	Unit	Waste Code(s)

Special Handling Instructions / Additional Information

Signatures

Generator Name/Signature

Date

Transporter Name/Signature

Date

Facility Name/Signature

Date