Consumption unit retirement form: solvent degreasing regulations

[see paragraph 5(1) and schedule 4 of solvent degreasing regulations]

Notes:

• This form must be used to make a consumption unit retirement notice.
• A separate consumption unit retirement notice must be made for consumption units issued for a given solvent and a specific degreasing process.

Step 1: retiree information

Retiree:

Name of referee, company or corporation:

Civic address of principal place of business:

Number and street:
city:
province:
postal code:

Postal address of principal place of business (if different from the civic address):

Number and street:
city:
province:
postal code:

Telephone number (include area code): ( )
fax number (if any - include area code): ( )
e-mail address (if any):

Step 2: request for confidentiality

Note: indicate if a request for confidentiality is being made under section 313 of the canadian environmental protection act (cepa) 1999 and the reason for the request.

Do you request confidentiality under section 313 of cepa 1999?

Yes or no

Reason:

Step 3: retiree facility information

Note: if more than five (5) facilities, attach additional copies of this page.

Facilities:

Number of facilities included in this notice: ___

Civic address of facility 1:

Number and street:
city:
province:
postal code:

Postal address of facility 1 (if different from the civic address):

Number and street:
city:
province:
postal code:

Civic address of facility 2:

Number and street:
city:
province:
postal code:

Postal address of facility 2 (if different from the civic address):

Number and street:
city:
province:
postal code:

Civic address of facility 3:

Number and street:
city:
province:
postal code:

Postal address of facility 3 (if different from the civic address):

Number and street:
city:
province:
postal code:

Civic address of facility 4:

Number and street:
city:
province:
postal code:

Postal address of facility 4 (if different from the civic address):

Number and street:
city:
province:
postal code:

Civic address of facility 5:

Number and street:
city:
province:
postal code:

Postal address of facility 5 (if different from the civic address):

Number and street:
city:
province:
postal code:

Step 4: solvent and degreasing process information

Solvent and degreasing process:

Effective date of retirement of consumption units (dd/mm/yy): __/__/__
name of solvent for which consumption units were issued (select one only): tce or perc
name of degreasing process for which consumption units were issued (select one only): vapour degreaser or cold degreaser
quantity of consumption units retired: __ kg
reason for retirement of consumption units:

Step 5: signature

I, __________________, (print name of retiree or person who is authorized to act on behalf of retiree) declare that the information provided in this solvent degreasing consumption unit retirement notice is correct.

Date:
place:
total number of pages in this notice:

____________________________
signature of retiree, or of person who is authorized to act on behalf of the retiree.

Submit the completed and signed solvent degreasing consumption unit retirement notice by mail to:

Solvent Degreasing Coordinator
Products Division, Chemicals Sector Directorate
Environment Canada
351 St. Joseph Blvd
Gatineau, Quebec
K1A 0H3

For assistance, call: 1-888-391-3426 or email: products.produits@ec.gc.ca