DexMetal

Sample Completed Forms

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Seeing properly completed Basel forms helps understand what competent authorities expect and how to present information clearly. This page provides detailed examples of completed notification forms and movement documents for different e-waste scenarios. While these are illustrative examples, they demonstrate best practices for form completion and can serve as templates for your own notifications.

Important Disclaimers

THESE ARE EXAMPLES ONLY:

  • Sample forms use fictional company names, addresses, and data
  • Provided for educational and training purposes
  • Actual notifications must contain accurate, current information
  • Do not copy verbatim—adapt to your specific situation
  • Always verify current form versions with competent authorities
  • Regulations and form requirements change—confirm before submission

VERIFY WITH COMPETENT AUTHORITIES:

  • Some countries use modified forms with additional fields
  • Electronic submission systems may have different formats
  • Language requirements vary by country
  • Always use most current form version available

Example 1: Circuit Board Export (USA to Belgium)

SCENARIO:

  • Waste Stream: Printed circuit boards from electronics recycling
  • Exporter: TechRecycle Solutions (United States - non-Party)
  • Importer: European Metals Recovery NV (Belgium)
  • Facility: Umicore Precious Metals Refining, Hoboken, Belgium
  • Classification: A1181 (hazardous e-waste), Y31 (lead), H6.1/H11/H12
  • Operation: R4 (metal recycling)
  • Notification Type: General notification for 12 months
  • Article 11 Agreement: USA-Belgium does not exist (but OECD procedures apply)

KEY FORM ENTRIES:

Block 1: Reason for Export

  • Selection: R4 - Recycling/reclamation of metals and metal compounds
  • Explanation: "Recovery of copper, gold, silver, and palladium from printed circuit boards at precious metals refinery"

Block 3: Exporter Details

  • Name: TechRecycle Solutions, LLC
  • Address: 1234 Recycling Way, Newark, NJ 07102, United States
  • Contact: John Smith, Compliance Manager
  • Tel: +1-973-555-0100
  • Email: jsmith@techrecycle.example.com
  • Registration: EPA ID# NJD987654321

Block 4: Importer Details

  • Name: European Metals Recovery NV
  • Address: Metalstraat 45, 2030 Antwerp, Belgium
  • Contact: Marie Dubois, Operations Director
  • Tel: +32-3-555-0200
  • Email: mdubois@eurometals.example.be
  • Registration: BE0123456789 (Belgian company number)

Block 5: Actual Disposal/Recovery Facility

  • Name: Umicore Precious Metals Refining
  • Address: Kasteelstraat 7, 2660 Hoboken, Belgium
  • Contact: Dr. Jan Peeters, Facility Manager
  • Tel: +32-3-555-0300
  • Email: jpeeters@umicore.example.com
  • License: Environmental Permit VL-2020-001234 (OVAM)

Block 11: Means of Transport and Packaging

  • Transport: Truck from Newark, NJ to Port of New York/New Jersey → Ocean container to Port of Antwerp → Truck to Hoboken facility
  • Packaging: Printed circuit boards packed in UN-certified steel drums (UN 1A2/X200/S), approximately 200kg per drum, 100 drums per shipment. Drums palletized and containerized in 40' shipping containers.
  • Special Handling: Classified as UN 3077 (Environmentally Hazardous Substance, Solid, N.O.S.) Class 9, Packing Group III for transport.

Block 12: Countries Concerned

  • State of Export: United States of America (Competent Authority: EPA, Office of Resource Conservation and Recovery)
  • State of Import: Belgium (Competent Authority: OVAM - Public Waste Agency of Flanders)
  • State(s) of Transit: None if ocean route through international waters. If transiting French or Dutch territorial waters, additional notifications required.

Block 14: Waste Identification

  • Basel Annex VIII (hazardous): A1181
  • Y-code: Y31 (lead; lead compounds)
  • UN Class: 9 (UN 3077)
  • H-code(s): H6.1 (Poisonous - acute), H11 (Toxic - delayed), H12 (Ecotoxic)
  • OECD Code: Not applicable (not green or amber list - full notification required)
  • National Classification (US): EPA hazardous waste D008 (lead)

Block 15: Physical Characteristics

  • Description: Printed circuit boards removed from end-of-life computers, servers, and telecommunications equipment. Boards vary in size from small smartphone boards to large server motherboards. Components include integrated circuits, capacitors, resistors, and connectors soldered to fiberglass substrate.
  • Physical State: Solid
  • Estimated Quantity per Shipment: 20,000 kg (20 metric tons)
  • Total Quantity (General Notification): 240,000 kg over 12 months (12 monthly shipments)

Block 16: Waste Composition

  • Copper: 15% by weight
  • Fiberglass/Epoxy Resin: 55%
  • Integrated Circuits & Components: 20%
  • Lead (solder): 2%
  • Gold: 250 ppm (0.025%)
  • Silver: 1,500 ppm (0.15%)
  • Palladium: 100 ppm (0.01%)
  • Brominated Flame Retardants:
  • Other metals and plastics: Balance
  • Hazardous Constituents: Lead primarily from solder joints (pre-RoHS boards); brominated flame retardants in substrate resin

Block 17: Disposal/Recovery Operations

  • D-code: Not applicable (recovery not disposal)
  • R-code: R4 (Recycling/reclamation of metals and metal compounds)
  • Technology: Integrated smelting and refining processes. Circuit boards fed to copper smelter operating at 1,200°C. Copper, precious metals (gold, silver, palladium), and other metals recovered through pyrometallurgical and hydrometallurgical refining. Slag utilized in construction materials. Atmospheric emissions controlled through baghouse filtration and acid gas scrubbing.

Block 18: Intended Date(s) of Shipment(s)

  • General Notification: One shipment per month over 12-month period
  • Expected first shipment: March 15, 2026
  • Expected final shipment: February 28, 2027
  • Advance notification: 7 days before each shipment as required by Belgian authorities

Block 19: Special Handling Requirements

  • Packaging: UN-certified drums prevent spillage during transport
  • Dangerous Goods: Classified as Class 9, requires dangerous goods declaration
  • No special temperature or pressure requirements
  • Keep dry to prevent water absorption by substrate materials

Block 20: Exporter/Generator Declaration

  • Signed by: John Smith, Compliance Manager, TechRecycle Solutions, LLC
  • Date: February 1, 2026
  • Declaration: "I certify that the above information is complete and correct to the best of my knowledge. The waste will be managed in an environmentally sound manner throughout the period of transboundary movement and at the recovery facility."

SUPPORTING DOCUMENTS ATTACHED:

  • Contract between TechRecycle Solutions and European Metals Recovery NV
  • Umicore facility environmental permit (OVAM VL-2020-001234)
  • Waste characterization report with laboratory analysis (XRF and ICP-MS)
  • Certificate of insurance ($500,000 environmental liability coverage)
  • EPA notification acknowledgment for US export
  • ESM documentation for Umicore facility (ISO 14001 certificate, process description)

Example 2: LCD Display Export (Germany to Belgium)

SCENARIO:

  • Waste Stream: LCD monitors with mercury backlights
  • Exporter: EcoElektronik GmbH (Germany)
  • Importer: RecycleLux SPRL (Belgium)
  • Facility: Specialized LCD Processing Facility, Brussels, Belgium
  • Classification: A1181, Y29 (mercury), H6.1/H11/H12
  • Operation: R4 (metal recovery), R5 (glass recovery), D10 (incineration of mercury lamps)
  • Notification Type: Individual notification (single shipment)
  • EU Regulation 1013/2006: Annex VII procedure (intra-EU)

KEY DIFFERENCES FROM EXAMPLE 1:

Block 1: Reason for Export

  • R4/R5 - Recovery of metals (from internal components) and glass (from LCD panels)
  • D10 - Incineration of mercury-containing backlights in specialized facility
  • Note: Mixed R and D operations require justification why disposal component cannot be avoided

Block 11: Means of Transport

  • Transport: Truck from Hamburg, Germany to Brussels, Belgium via Netherlands (transit notification required)
  • Packaging: LCD monitors packed upright in wooden crates with protective padding. Mercury backlight lamps remain installed in units. Each crate labeled with "FRAGILE" and mercury hazard warning labels.
  • Special Handling: Classified as UN 3077. Additional mercury hazard labeling. Careful handling to prevent breakage of mercury lamps.

Block 12: Countries Concerned

  • State of Export: Germany (Umweltbundesamt - Federal Environment Agency)
  • State of Import: Belgium (Bruxelles Environment - Brussels Region competent authority, since facility in Brussels)
  • State(s) of Transit: Netherlands (ILT - Human Environment and Transport Inspectorate). Transit notification submitted separately.

Block 14: Waste Identification

  • Basel Annex VIII: A1181
  • Y-code: Y29 (Mercury; mercury compounds) - Primary hazard
  • Also: Y31 (Lead from circuit boards, solder)
  • EU Waste List: 16 02 13* (discarded equipment containing hazardous components)
  • H-codes: H6.1, H11, H12 (mercury toxicity)

Block 15: Physical Characteristics

  • Description: LCD computer monitors (17" to 27" diagonal), manufactured 2005-2015, containing cold cathode fluorescent lamp (CCFL) backlights with mercury content. Each backlight contains approximately 3-5mg mercury. Monitors include LCD panel, plastic housing, metal frame, control circuit boards, and power supply.
  • Physical State: Solid (intact equipment)
  • Quantity: 10,000 units (approximately 100,000 kg)

Block 16: Waste Composition

  • LCD Glass Panel: 40%
  • Plastic Housing: 30%
  • Circuit Boards: 10%
  • Metal Frame and Supports: 15%
  • CCFL Backlights: 2% (contains 30-50g total mercury for entire shipment)
  • Other Components: 3%
  • Hazardous Constituents: Mercury in CCFL backlights (primary hazard); lead in solder on circuit boards; brominated flame retardants in plastic housing

Block 17: Operations

  • R4: Recovery of copper, aluminum, and other metals from circuit boards and frames
  • R5: Recovery of glass from LCD panels (after removal of liquid crystal layer)
  • D10: Incineration of mercury-containing CCFL backlights in permitted mercury waste incinerator with mercury capture systems
  • Process: Manual dismantling → Remove mercury backlights → Separate incineration of backlights with mercury recovery → Mechanical processing of remaining components for metal and glass recovery

EU-SPECIFIC DOCUMENTATION:

  • Annex VII notification document (simplified intra-EU form)
  • Financial guarantee: Bank guarantee for €50,000 covering transport and 90-day storage
  • Reference to EU Regulation 1013/2006 instead of pure Basel procedures
  • 30-day tacit consent period (may be shortened with agreement)

Example 3: Movement Document (Annex V B)

SCENARIO: Circuit Board Shipment (From Example 1 Above)

SECTION A: NOTIFICATION DETAILS (Completed by Exporter)

  • 1. Notification Number: US-2026-0123 (assigned by US EPA)
  • 2. Serial Number of Shipment: 001 (first shipment under general notification)
  • 3. Total Number of Shipments: 12 (under this general notification)
  • 4. Exporter Notification Number (if different): Same
  • 5. Importer Notification Number (if different): BE-2026-0456 (assigned by OVAM)

SECTION B: INFORMATION ON SHIPMENT (Completed by Exporter)

  • 6. Exporter: TechRecycle Solutions, LLC, 1234 Recycling Way, Newark, NJ 07102, USA
  • 7. Importer: European Metals Recovery NV, Metalstraat 45, 2030 Antwerp, Belgium
  • 8. Actual Facility: Umicore Precious Metals Refining, Kasteelstraat 7, 2660 Hoboken, Belgium
  • 9. Carrier(s): ABC Trucking (USA leg), Atlantic Shipping Lines (ocean), XYZ Transport (Belgium leg)
  • 10. Waste Description: Printed circuit boards - Basel Code A1181, Y31, UN 3077
  • 11. Quantity: 20,000 kg (100 drums × 200 kg each)
  • 12. Packaging Type: Steel drums, UN 1A2/X200/S
  • 13. Special Handling: Class 9 dangerous goods, keep dry
  • 14. Date Shipment Commenced: March 15, 2026

SECTION C: CERTIFICATION BY EXPORTER (Signed before shipment)

  • Name: John Smith, Compliance Manager
  • Signature:
  • Date: March 15, 2026
  • Declaration: "I certify that the information is complete and correct. All applicable requirements have been met. This shipment is authorized under general notification US-2026-0123."

SECTION D: CERTIFICATION BY CARRIER (Signed upon receipt of shipment)

  • Carrier Name: ABC Trucking Company
  • Driver Name: Robert Johnson
  • Signature:
  • Date of Receipt: March 15, 2026, 10:00 AM
  • Declaration: "I have received the waste described above for transport to Port of New York/New Jersey for ocean shipment to Port of Antwerp, Belgium."

(Transfer at ocean terminal - additional carrier certification)

  • Carrier Name: Atlantic Shipping Lines
  • Container/Vessel: Container ATLU1234567 loaded on M/V Atlantic Pride, Voyage 123
  • Signature:
  • Date: March 16, 2026
  • Departed: March 17, 2026
  • Arrived Port of Antwerp: March 30, 2026

(Transfer at Antwerp - additional carrier certification)

  • Carrier Name: XYZ Transport BVBA
  • Driver Name: Marc Vermeulen
  • Signature:
  • Date of Receipt: March 31, 2026

SECTION E: CERTIFICATION BY IMPORTER/FACILITY (Signed upon arrival at facility)

  • Name: Marie Dubois, Operations Director, European Metals Recovery NV
  • Signature:
  • Date of Arrival: March 31, 2026
  • Quantity Received: 20,000 kg (100 drums, all seals intact)
  • Declaration: "I certify receipt of the waste described above. Waste matches the notification. No discrepancies noted."

SECTION F: CERTIFICATION BY DISPOSER (Signed after processing complete)

  • Name: Dr. Jan Peeters, Facility Manager, Umicore Precious Metals Refining
  • Signature:
  • Date Processing Completed: April 28, 2026
  • Operation Completed: R4 - Recycling/reclamation of metals
  • Declaration: "I certify that recovery of this waste has been completed on the date specified in accordance with the notification and applicable regulations. Metals recovered and residues managed in accordance with permits."

MOVEMENT DOCUMENT DISTRIBUTION:

  • Copy sent to US EPA: May 5, 2026
  • Copy sent to OVAM (Belgium): May 5, 2026
  • Copy retained by TechRecycle Solutions: Filed for 7 years
  • Copy retained by Umicore: Filed for 7 years

Key Elements Demonstrated

COMPLETENESS:

  • All blocks filled out (no blank required fields)
  • Specific details rather than vague descriptions
  • Consistent information across notification and movement document
  • Cross-references between related blocks (e.g., Block 14 codes match Block 17 operations)

ACCURACY:

  • Waste codes properly selected and justified
  • Quantities realistic and verifiable
  • Facility authorizations match waste codes and operations
  • Contact information current and complete
  • Supporting documents referenced

CLARITY:

  • Technical descriptions understandable to non-experts
  • Hazards clearly identified
  • Operations described in sufficient detail
  • Transport routing specific
  • Special requirements explained

PROFESSIONALISM:

  • Proper grammar and spelling
  • Organized presentation
  • Complete sentences in narrative blocks
  • Consistent formatting
  • Signed declarations with proper authority

Common Errors to Avoid

  • Leaving required blocks blank or marking "N/A" without justification
  • Vague waste descriptions ("electronic waste" instead of specific component types)
  • Inconsistent information (Block 15 quantity doesn't match Block 16 composition)
  • Wrong waste codes (using Annex IX codes for clearly hazardous waste)
  • Missing H-codes when Annex VIII waste listed
  • R/D codes that don't match facility permits
  • Incomplete contact information (missing phone or email)
  • Unsigned declarations
  • Movement document signatures missing or in wrong sequence
  • Not distributing completed movement documents to authorities

Using Sample Forms Effectively

FOR TRAINING:

  • Walk through each block with staff
  • Explain why specific information chosen
  • Practice filling out forms with hypothetical scenarios
  • Review common errors and how samples avoid them

FOR PREPARING ACTUAL NOTIFICATIONS:

  • Use samples as reference for level of detail expected
  • Adapt language and structure to your specific waste
  • Don't copy verbatim—personalize to your situation
  • Verify your facility permits match operations listed
  • Have experienced reviewer check before submission

FOR QUALITY CONTROL:

  • Compare your completed forms to samples
  • Check for similar level of detail and completeness
  • Verify all cross-references consistent
  • Ensure declarations properly signed
  • Confirm supporting documents attached

References

Section: Additional Ref · Type: reference