WHEELABRATOR PORTSMOUTH MANIFEST FORM

FOR THE DESTRUCTION OF PROPRIETARY WASTE

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GENERATOR INFORMATION MANIFEST NUMBER:
Generator Name:
Address:
City/State/Zip: ,
Contact:    Phone:
Generator Code:   Approval Number:   Purchase Order:
MATERIAL INFORMATION
Description Quantity Units of Measure
Lbs, gals, Tons, Drums, Skids
Lbs, gals, Tons, Drums, Skids
Lbs, gals, Tons, Drums, Skids
Lbs, gals, Tons, Drums, Skids
I certify that the waste being transported to Wheelabrator Portsmouth Inc. is RCRA nonhazardous according to Federal and
State regulations and does not contain Regulated Medical Waste and/or PCBs. I certify that the waste is of the same type and
composition as specifically approved by Wheelabrator Portsmouth Inc. and is free of substances not authorized for acceptance
at the disposal facility.
Generator Signature:   Title:
Company: Date:
Transportation Information
Transporter Company Name:
Driver Name:
I certify this material was received from the generator identified above and delivered to the Facility identified above in accordance
with Wheelabrator Portsmouth's Rules and Regulations.
Driver's Signature: Date:
COMMENTS
DISPOSAL FACILITY INFORMATION
I certify that the materials described above were received by the faciltiy on this manifest and were processed and disposed in
accordance with Wheelabrator Portsmouth's Rules and Regulations.
Disposal Facility Signature & Title: Date: