Revised pollution prevention plans for inorganic chloramines and chlorinated wastewater effluents: schedule 3

Schedule 3: Request for Time Extension - Inorganic Chloramines and Chlorinated Wastewater Effluents (Subsection 56(3) of CEPA 1999)

NOTE: Please contact the National Office of Pollution Prevention for more information about electronic reporting or the filing of paper forms.

Notice Reference Code:P2CLMWWE

• 1.0 Information on the Person or Class of Persons Subject to the Notice
• 2.0 Request for Time Extension
• 3.0 Rationale for Request
• 4.0 Certification

Please refer to the instruction booklet "Instructions for Completing the Schedules of the Canada Gazette Notice Requiring the Preparation and Implementation of Pollution Prevention Plans for Inorganic Chloramines and Chlorinated Wastewater Effluents" for guidance on how to complete this Request. Electronic copies of the Notice, and the instructions for completing the declarations (Schedules 1 to 5), are available from the Pollution Prevention website, or can be requested by telephone at 819-994-0186, by fax at 819-953-7970, or by email; CEPAP2Plans@ec.gc.ca.

1.0 Information on the Person or Class of Persons Subject to the Notice

Name of the Person or Class of Persons Subject to the Notice: ____________
Facility Name: ____________
Street Address of Facility: ____________
City: ____________
Province/Territory: ____________
Postal Code: ____________
Telephone number: (with area code) ____________
e-mail (if available): ____________

If different from Street Address
Mailing Address of Facility: ____________
City: ____________
Province/Territory: ____________
Postal Code: ____________

National Pollutant Release Inventory ID (if no ID, leave blank): ____________
6-digit North American Industry Classification System (NAICS) Code: 221320

Facility Technical Contact: ____________
e-mail (if available): ____________
Telephone Number: (with area code) ____________
Fax Number (if available): (with area code) ____________

2.0 Request for Time Extension

Identify for which of the following a time extension is requested (choose one):

 to prepare a pollution prevention plan.

 to implement a pollution prevention plan.

For the person(s) identified in Part 1.0, it is requested that the date be extended to: _____________________ (specify exact date - year/month/day)

3.0 Rationale for Request

Explain why further time is necessary to prepare or implement a pollution prevention plan.

4.0 Certification

I hereby certify that the information provided in this Request is true, accurate and complete.

___________________________________________________________
Signature of the Person(s) subject to the Notice or Duly Authorized Representative

___________________________________________________________
Date

Name:
___________________________________________________________
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Title/Position:
___________________________________________________________
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