Generator Information

  • Company Name: [Your Business Name]
  • Address: [Your Business Address]
  • Phone Number: [Your Phone Number]
  • EPA ID Number (if applicable): [Your EPA ID Number (optional)]

Manifest Information

  • Manifest Number: [Unique Manifest Number]
  • Date: [Date of Waste Collection]
  • Hauler Information:
    • Company Name: [Waste Disposal Company Name]
    • EPA ID Number: [Waste Disposal Company EPA ID Number]
    • Phone Number: [Waste Disposal Company Phone Number]
  • Facility Information:
    • Name: [Waste Disposal Facility Name]
    • Address: [Waste Disposal Facility Address]
    • EPA ID Number: [Waste Disposal Facility EPA ID Number]

Waste Description

Item # Description of Waste UN/NA Code Quantity (lbs) Waste Stream (check all that apply)
1 Blood and Bodily Fluids 3266   Infectious Waste (check if applicable) <br> Pathological Waste (check if applicable) <br> Sharps Waste (check if applicable)
 
 

Special Handling Instructions: [Indicate any specific handling requirements for the waste, e.g., refrigeration, double-bagging]

Generator Certification

I hereby certify that the above information is complete and accurate. The waste listed on this manifest is packaged, labeled, and marked in accordance with all applicable regulations.

  • Signature: _______________________ (Authorized Representative)
  • Printed Name: _______________________
  • Date: _______________________

Hauler Certification

I hereby certify that the above-described waste was picked up from the generator on the above date and will be disposed of in accordance with all applicable regulations.

  • Signature: _______________________ (Hauler Representative)
  • Printed Name: _______________________
  • Date: _______________________

Disposal Facility Certification

I hereby certify that the above-described waste was received on the above date and will be managed and disposed of in accordance with all applicable regulations.

  • Signature: _______________________ (Disposal Facility Representative)
  • Printed Name: _______________________
  • Date: _______________________