Disposal at sea: permit renewal application form
Permit to be Renewed
Permits are issued in accordance with Division 3 of Part 7 of the Canadian Environmental Protection Act, 1999 (the "Act"). "Disposal" has the same meaning as in subsection 122(1) of the Act. Information provided on this form will be used to evaluate the application for a permit renewal. Information collected is intended to verify that no conditions that informed the decision to issue the original permit have changed since the original permit application.
| Original Permit No.: 4543-2-0_______________ |
Original Expiry Date (year/month/day): _______________ |
Part A - Identification and Applicant Information
| 1. Name of Applicant |
2. Telephone No. | 3-4. Email Address/Fax No. |
| 5. Address |
6. Type of Business | |
| 7. Name of Individual(s) Responsible for Proposed Activity |
8. Telephone No. | 9-10. Email Address/Fax No. |
| 11. Name of Technical Contact(s) for Proposed Activity |
12. Telephone No. | 13-14. Email Address/Fax No. |
Part B - Information on the Proposed Activity and General Information
15. Description of Activity - Describe in detail any changes to the information provided in the original permit application.
Number of pages attached ____ |
16. Term of Permit Requested
|
17. Total Quantity (m3 or tonnes) - Indicate the maximum quantity requested for disposal under the renewed permit. |
18. New Approvals - List all permits, licences and reviews, including environmental impact assessments, that are required by any federal, provincial, territorial, municipal or local agency for the carrying out of the activity described in this application and that were received since the original permit application was submitted.
| Issuing Agency |
Type of Approval |
ID No. |
Date of Application (year/month/day) |
Date of Approval (year/month/day) |
19. Notice of Application - Attach evidence that a notice was published under paragraph 127(2)(d) of the Act.
| Clipping attached___ | ||
| Name of publication |
Place of publication (city, province) |
Date of publication (year/month/day) |
Part C - Carrier Information
If unknown, this information may be provided at a later date, but prior to start of operations.
| 20. Name and address of carrier |
21. Telephone No. | 22-23. Email Address/Fax No. |
| 24. Name, title and address of owner of ship, aircraft, platform or structure used to carry out disposal |
25. Telephone No. | 26-27. Email Address/Fax No. |
| 28. Name of individuals responsible for loading or disposal on behalf of Applicant (including the master) |
29. Telephone No. | 30-31. Email Address/Fax No. |
| 32. Name or number of ship, aircraft, platform or structure used to carry out disposal |
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If this application is to be submitted by an agent of the Applicant, the Applicant must complete the following authorization: I authorize _____________________________________(print name) to act on my behalf as my agent in the processing of this application and to furnish, on request, supplemental information in support of this application. |
||
| Date |
Name (print) |
Signature |
| This application is made for the renewal of a permit authorizing the activity described in this application. I certify that I have reviewed the information provided in the original permit application and that it is still complete and accurate with the exception of updated information provided in this application for renewal. I certify that I have reviewed the information provided in this application and that, to the best of my knowledge and belief, the information is true, complete and accurate. I further certify that I am authorized to undertake the proposed activity or am acting as the Applicant's duly authorized agent. | ||
| Date |
Name (print) |
Signature |
| Telephone No. |
Fax No. |
|
Send the completed permit renewal application, the application fee, and all supporting documentation to the nearest Disposal at Sea Program office of Environment Canada.