Annex VII Form- Information Accompanying Shipments of Waste

Consignment information (1)

1. Person who arranges the shipment:

Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Contact person *

Phone Number *

Fax Number (if any)

Email Address *

2. Importer/consignee

Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Contact Person *

Phone Number *

Fax Number (if any) *

Email Address *

3. Actual quantity

Tonnes *

Cubic meters *

4. Actual date of shipment *

5(a) (2) First carrier:

Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Contact person *

Phone Number *

Fax Number *

Email

Means of transport *

Date of transfer: *

5(b) Second carrier:

Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Contact person *

Phone Number *

Fax Number *

Email

Means of transport *

Date of transfer: *

5(c) Third carrier

Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Contact person *

Phone Number *

Fax Number *

Email

Means of transport *

Date of transfer: *

6. Waste generator (3)

Original producer(s), new producer(s) or collector:

Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Contact person *

Phone Number *

Fax Number *

Email

7. Location

Tick in relevant *

Recovery facility

Laboratory

Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Contact person *

Phone Number *

Fax Number *

Email

8. Recovery operation (or if appropriate disposal operation in the case of waste referred to in Article 3(4)

R-code/D code *

9. Usual description of the waste

*

10. Waste identification (fill in relevant codes)

(i) Basel Annex IX:

(ii) OECD (if different from (i)):

(iii) EC list of wastes:

(iv) National code:

11. Countries/states concerned:

Export/dispatch

Transit

Import/destination

12. Declaration of the person who arranges the shipment:

I certify that the above information is complete and correct to my best knowledge. I also certify that effective written contractual obligations have been entered into with the consignee (not required in the case of waste referred to in Article 3(4)): *

Yes

Name *

Date *

13. Signature upon receipt of the waste by the consignee:

Name

Date

14.TO BE COMPLETED BY THE RECOVERY FACILITY OR BY THE LABORATORY

Shipment received *

at recovery facility

or laboratory

Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Contact person *

Phone Number *

Quantity received

kg

Quantity received

litre

Name

Date

(1) Information accompanying shipments of green listed waste and destined for recovery or waste destined for laboratory analysis pursuant to Regulation (EC) No.1013/2006.

(2) If more than three carriers, attach information as required in blocks 5(a), (b) and (c).

(3) When the person who arranges the shipment is not the producer or collector, information about the producer or collector shall be provided.

Applicant will be required to sign application form prior to document being issued by the Agency.

Fax Number *

Email

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