1. Person who arranges the shipment
Name:
Address:
Contact person:
Tel.: Fax:
E-mail
|
2. Importer/consignee
Name:
Address:
Contact person:
Tel.: Fax:
E-mail
|
3. Actual quantity: Tonnes (Mg): m3:
|
4. Actual date of shipment:
|
5.(a) 1st carrier (2)
Name:
Address:
Contact person:
Tel.:
Fax:
E-mail:
Means of transport:
Date of transfer:
Signature:
|
5.(b) 2nd carrier
Name:
Address:
Contact person:
Tel.:
Fax:
E-mail:
Means of transport:
Date of transfer:
Signature:
|
5.(c) 3rd carrier
Name:
Address:
Contact person:
Tel.:
Fax:
E-mail:
Means of transport:
Date of transfer:
Signature:
|
6. Waste generator (3)
Original producer(s), new producer(s) or collector:
Name:
Address:
Contact person:
Tel.: Fax:
E-mail:
|
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:
|
7. Recovery facility Laboratory
Name:
Address:
Contact person:
Tel.: Fax:
E-mail:
|
10. Waste identification (fill in relevant codes):
(i) Basel Annex IX:
(ii) OECD (if different from (i)):
(iii) Annex IIIA (4):
(iv) Annex IIIB (5):
(v) EC list of wastes:
(vi) 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)):
Name: Date: Signature:
|
13. Signature upon receipt of the waste by the consignee:
Name: Date: Signature:
|
To be completed by the Recovery facility or by the Laboratory:
|
14. Shipment received at recovery facility or laboratory Quantity received: Tonnes (Mg): m3:
Name: Date: Signature:
|
(4) The relevant code(s) as indicated in Annex IIIA to Regulation (EC) No 1013/2006 are to be used, as appropriate in sequence. Certain Basel entries such as B1100, B3010 and B3020 are restricted to particular waste streams only, as indicated in Annex IIIA.