The Hazardous Waste Regulations 2005: Consignment Note

• Site conducted

  Select

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Yes

  No

  N/A

PART A Notification details

• 1 Consignment note code:

• 3 The waste will be taken to (name, address and postcode):

• 2 The waste described below is to be removed from (name, address, postcode, telephone, e-mail):

  Yes

  No

  N/A

• 4 The waste producer was (if different from 2)

  Yes

  No

  N/A

• (name, address, postcode, telephone, e-mail, facsimile):

WASTE DETAILS

• The process giving rise to the waste(s) was: de-gassing of cooling/heating units

  Yes

  No

  N/A

• List of wastes EWC code

• Description of waste eg Refrigerant/compressor oil

• Barcode/cylinder/bottle serial number

• Quantity/KG

Component

• 2 SIC (2007) for the process giving rise to the waste:

• Physical form:eg Gas,Liquid

• Non-flammable refrigerant gas

  Yes

  No

  N/A

• CFC/HCFC/HFC refrigerants

  Yes

  No

  N/A

• Waste AK flush

  Yes

  No

  N/A

• Flammable refrigerant gas

  Yes

  No

  N/A

• Trans 1, 2-dichloroethylene

  Yes

  No

  N/A

• Carbon Dioxide

  Yes

  No

  N/A

PART C Carrier’s certificate

PART C Carrier's certificate

• I certify that I today collected the consignment and that the details in A2, A3 and B3 are correct and I have been advised of any specific handling requirements

  Sign

• Carrier Business Name:

• Carrier Individual Full Name:

• Carrier Address:

• Carrier registration no./reason for exemption:

• Signature:

  Sign

• Vehicle registration no. (or mode of transport, if not road):

• Date and Time

  Date

PART D Consignor’s certificate

• I certify that I the infomation in A,B and Chas been completed and is correct,the carrier is registered or exempt and was advised of the appropriate precautionary measures.all of tyhe waste is packaged and labeled correctly and the carrier has been advised of any special handling requirements.

  Sign

• Consignor Company Name:

• Consignor Name:

• I confirm that I have fulfilled my duty to apply the waste hierarchy as required by Regulation 12 of the Waste (England and Wales)

• Signature:

  Sign

• Time H H M M

  Date

PART E Consignee’s certificate

• I received this waste at the address given in A3 on:

  Yes

  No

  N/A

• Vehicle registration no. (or mode of transport if not road):

  Yes

  No

  N/A

• Quantity of each EWC code received (kg)

• Where waste is rejected please provide details:

  Yes

  No

  N/A

• I certify that waste permit/exempt waste operation number:

• Waste management operation (R or D code)

  Yes

  No

  N/A

• Name:

• Signature

  Sign

• authorises the management of the waste described in B at the address given in A3

  Yes

  No

  N/A

• Date and Time

  Date