The Hazardous Waste Regulations 2005: Consignment Note Producer’s/ Holder’s / Consignor’s

Original

Part A:Notification Details

1. Consignment Note Code: 1 2 3 4 5 6 / 2 0 2 1 4. The waste will be taken to (name, address & postcode):

2. The waste described below is to be removed from (name, address, postcode,

telephone, e-mail, facsimile): 5. The waste producer was (if different from 2.) (name, address,
postcode, telephone, e-mail, facsimile):

3. Premises Code (where applicable):

Part B: Description of the waste If continuation sheet used tick here 

1. The process giving rise to the waste(s) was: 2 SIC for the process giving rise to the waste

3. WASTE DETAILS (where more than one waste type is collected all of the information given below must be completed for each EWC identified)
List of The chemical/biological components in the waste Physical Form (Gas, Container
Quant and their concentrations are Haza
Description of waste Wastes Liquid, Solid, type,
ity Component Concentration (% or mg/kg) rd
(EWC) code Powder, Sludge or number &
(kg): code(
(6 digits): Mixed): size:
s):

The information given below is to be completed for each EWC identified

UN Proper
EWC Code identification shipping UN Class(es) Packing Group(s) Special handling requirements
number(s) name(s)

Part C Carrier’s certificate Part D Consignor’s certificate

(If more than one carrier is used, please attach Schedule for subsequent carriers. If I certify that the information in A, B and C has been completed and is
schedule of carriers is attached tick here  ). correct, that the carrier is registered or exempt and was advised of the
I certify that I today collected the consignment and that the details in A2, A4 and B3 are appropriate precautionary measures. All of the waste is packaged and
correct and I have been advised of any specific handling requirements. labelled correctly and the carrier has been advised of any special
Where this consignment forms part of a multiple collection, the round number and collection handling requirements.
number are I confirm that I have fulfilled my duty to apply the waste hierarchy as
/ required by Regulation 12 of the Waste (England and Wales)
Regulations 2011.
1. Carrier Name:
Consignor Name:
On behalf of (name, address, postcode, telephone, e-mail, facsimile):
On behalf of (name, address, postcode, telephone, e-mail, facsimile):

2. Carrier registration no./ reason for exemption:

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

Signature Signature

Date D D M M Y Y Tim H H M M Date D D M M Y Y Tim H H M M

e e
Part E Consignee’s certificate (where more than one waste type is collected all of the information given below must be
completed for each EWC)

EWC Waste Management operation (R or D

Individual EWC code(s) received Quantity of each EWC code received (kg) Accepted/Rejected code)

1. I received this waste at the address given in A4 on Date D D M M Y Y At : Time H H M M

2. Vehicle registration no (or mode of transport, if not road) Name

3. Where waste is rejected please provide details: On behalf of (name, address, postcode, telephone, e-mail, facsimile) I

certify that waste permit / exempt waste operation number:

authorises the management of the waste described in B at the address given in A4

Signature Where the consignment forms part of a multiple collection, as identified in Part C, I
certify that the total number of consignments forming the collection are:: Dat D D M M Y Y Ti H H M M
e me
 The Hazardous Waste Regulations 2005: Consignment Note Carrier’s Copy

Part A:Notification Details

4. Consignment Note Code: / 4. The waste will be taken to (name, address & postcode):

5. The waste described below is to be removed from (name, address, postcode, telephone, e-
mail, facsimile):
5. The waste producer was (if different from 2.) (name, address,
postcode, telephone, e-mail, facsimile):

6. Premises Code (where applicable):

Part B: Description of the waste If continuation sheet used tick here 

2. The process giving rise to the waste(s) was: 3 SIC for the process giving rise to the waste

4. WASTE DETAILS (where more than one waste type is collected all of the information given below must be completed for each EWC identified)
List of The chemical/biological components in the waste Physical Form (Gas, Container
Quant and their concentrations are Haza
Description of waste Wastes Liquid, Solid, type,
ity Component Concentration (% or mg/kg) rd
(EWC) code Powder, Sludge or number &
(kg): code(
(6 digits): Mixed): size:
s):

The information given below is to be completed for each EWC identified

UN Proper
EWC Code identification shipping UN Class(es) Packing Group(s) Special handling requirements
number(s) name(s)

Part C Carrier’s certificate Part D Consignor’s certificate

(If more than one carrier is used, please attach Schedule for subsequent carriers. If I certify that the information in A, B and C has been completed and is
schedule of carriers is attached tick here  ). correct, that the carrier is registered or exempt and was advised of the
I certify that I today collected the consignment and that the details in A2, A4 and B3 are appropriate precautionary measures. All of the waste is packaged and
correct and I have been advised of any specific handling requirements. labelled correctly and the carrier has been advised of any special
Where this consignment forms part of a multiple collection, the round number and collection handling requirements.
number are I confirm that I have fulfilled my duty to apply the waste hierarchy as
/ required by Regulation 12 of the Waste (England and Wales)
Regulations 2011.
2. Carrier Name:
Consignor Name:
On behalf of (name, address, postcode, telephone, e-mail, facsimile):
On behalf of (name, address, postcode, telephone, e-mail, facsimile):

2. Carrier registration no./ reason for exemption:

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

Signature Signature

Date D D M M Y Y Time H H M M Date D D M M Y Y Time H H M M

Part E Consignee’s certificate (where more than one waste type is collected all of the information given below must be
completed for each EWC)

EWC Waste Management operation (R or D

Individual EWC code(s) received Quantity of each EWC code received (kg) Accepted/Rejected code)

4. I received this waste at the address given in A4 on Date D D M M Y Y At : Time H H M M

5. Vehicle registration no (or mode of transport, if not road) Name

6. Where waste is rejected please provide details: On behalf of (name, address, postcode, telephone, e-mail, facsimile) I

certify that waste permit / exempt waste operation number:

authorises the management of the waste described in B at the address given in A4

Signature Where the consignment forms part of a multiple collection, as identified in Part C, I
certify that the total number of consignments forming the collection are::
The Hazardous Waste Regulations 2005: Consignment Note Carrier’s Copy
Date D D M M Y Y Time H H M M
 The Hazardous Waste Regulations 2005: Consignment Note Consignee’s Copy

Part A:Notification Details

7. Consignment Note Code: / 4. The waste will be taken to (name, address & postcode):

8. The waste described below is to be removed from (name, address, postcode, telephone, e-
mail, facsimile):
5. The waste producer was (if different from 2.) (name, address,
postcode, telephone, e-mail, facsimile):

9. Premises Code (where applicable):

Part B: Description of the waste If continuation sheet used tick here 

3. The process giving rise to the waste(s) was: 4 SIC for the process giving rise to the waste

5. WASTE DETAILS (where more than one waste type is collected all of the information given below must be completed for each EWC identified)
List of The chemical/biological components in the waste Physical Form (Gas, Container
Quant and their concentrations are Haza
Description of waste Wastes Liquid, Solid, type,
ity Component Concentration (% or mg/kg) rd
(EWC) code Powder, Sludge or number &
(kg): code(
(6 digits): Mixed): size:
s):

The information given below is to be completed for each EWC identified

UN Proper
EWC Code identification shipping UN Class(es) Packing Group(s) Special handling requirements
number(s) name(s)

Part C Carrier’s certificate Part D Consignor’s certificate

(If more than one carrier is used, please attach Schedule for subsequent carriers. If I certify that the information in A, B and C has been completed and is
schedule of carriers is attached tick here  ). correct, that the carrier is registered or exempt and was advised of the
I certify that I today collected the consignment and that the details in A2, A4 and B3 are appropriate precautionary measures. All of the waste is packaged and
correct and I have been advised of any specific handling requirements. labelled correctly and the carrier has been advised of any special
Where this consignment forms part of a multiple collection, the round number and collection handling requirements.
number are I confirm that I have fulfilled my duty to apply the waste hierarchy as
/ required by Regulation 12 of the Waste (England and Wales)
Regulations 2011.
3. Carrier Name:
Consignor Name:
On behalf of (name, address, postcode, telephone, e-mail, facsimile):
On behalf of (name, address, postcode, telephone, e-mail, facsimile):

2. Carrier registration no./ reason for exemption:

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

Signature Signature

Date D D M M Y Y Time H H M M Date D D M M Y Y Time H H M M

Part E Consignee’s certificate (where more than one waste type is collected all of the information given below must be
completed for each EWC)

EWC Waste Management operation (R or D

Individual EWC code(s) received Quantity of each EWC code received (kg) Accepted/Rejected code)

7. I received this waste at the address given in A4 on Date D D M M Y Y At : Time H H M M

8. Vehicle registration no (or mode of transport, if not road) Name

9. Where waste is rejected please provide details: On behalf of (name, address, postcode, telephone, e-mail, facsimile) I

certify that waste permit / exempt waste operation number:

authorises the management of the waste described in B at the address given in A4

Signature Where the consignment forms part of a multiple collection, as identified in Part C, I
certify that the total number of consignments forming the collection are::
Date D D M M Y Y Time H H M M
The Hazardous Waste Regulations 2005: Consignment Note Consignee’s Copy