SOLVENT DEGREASING ANNUAL SOLVENT CONSUMPTION REPORT
[See Paragraph 7(a) and Schedule 6 of Solvent Degreasing Regulations]

NOTE:  this form must be used to make the annual solvent consumption report.

Year for which annual solvent consumption report is being made: _______

 STEP 1: User Information

User:	
name of user, 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)
	
Person authorized to submit notice on behalf of user:  (if applicable)	
name:
	
title:
	
name of company:
	
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?

  No
  Yes   

Reason:
 STEP 3: User Facility Information

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

Facilities: 	

number of facilities included in this report:       __________
	
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

NOTES:   separate solvent and degreasing process information must be provided for each given solvent and specific degreasing process.
make and attach additional copies of pages where more than one given solvent and specific degreasing process is reported or additional space is required.
all quantities are to be reported in kilograms.

Solvent and degreasing process:	

name of solvent:  (select one only)                                                    TCE                                                          PERC  

name of degreasing process:  (select one only)                      VAPOUR DEGREASER                          COLD DEGREASER  

average annual consumption:  (paragraph 4(1)(e))                                              _______________Kg

consumption units issued:  (paragraph 4(5))                                                           _______________Kg

quantity in opening inventory:                                                                     _______________Kg

quantity supplied by sellers:                                                                      _______________Kg
              (from Step 5)

quantity supplied by others:                                                                       _______________Kg
              (from Step 6)

quantity transferred from other on-site uses:                                       _______________Kg
              (from Step 7)

quantity transferred from other off-site uses:                                     _______________Kg
              (from Step 8)

quantity reclaimed or recycled on-site:                                                   _______________Kg

quantity transferred on-site for other uses:                                         _______________Kg
              (from Step 9)

quantity transferred off-site for other uses:                                       _______________Kg
              (from Step 10)

quantity sold to others:                                                                            _______________Kg
              (from Step 11)

quantity transferred to others:                                                              _______________Kg
              (from Step 12)

quantity in closing inventory:                                                                   _______________Kg

 STEP 5: Quantity of Solvent Supplied by Sellers (if applicable)

date
supplied

seller name	

civic address	

quantity
(Kg)	

				

				

				

				

				

				

				

				

total

 STEP 6: Quantity of Solvent Supplied by Others (if applicable)

date
supplied

supplier name	

civic address	

quantity
(Kg)	

				

				

				

				

				

				

				

				

total

 STEP 7: Quantity of Solvent Transferred From Other On-Site Uses (if applicable)

date
transferred
	
other on-site use	
quantity
(Kg)	

			

			

			

			

			

			

			

total

 STEP 8: Quantity of Solvent Transferred From Other Off-Site Uses (if applicable)

date
transferred
	
other off-site use	
quantity
(Kg)	

			

			

			

			

			

			

			

total

 STEP 9: Quantity of Solvent Transferred On-Site For Other Uses (if applicable)

date
transferred
	
other on-site use	
quantity
(Kg)	

			

			

			

			

			

			

			

total

 STEP 10: Quantity of Solvent Transferred Off-Site For Other Uses (if applicable)

date
transferred
	
other off-site use	
quantity
(Kg)	

			

			

			

			

			

			

			

total

 STEP 11: Quantity of Solvent Sold To Others (if applicable)

date
of
 sale

purchaser name	

civic address	

quantity
(Kg)	

				

				

				

				

				

				

				

total

 STEP 12: Quantity of Solvent Transferred to Others (if applicable)

date
of
transfer

transferee name	

civic address	

quantity
(Kg)	

				

				

				

				

				

				

				

total

 STEP 13: Signature

I, __________________________, (print name of user or person who is authorized to act on behalf of user) declare that the information provided in this solvent degreasing annual solvent consumption report is correct.

Date: ____________________

Place: ___________________

Total number of pages in this report: _______

_________________________________________
Signature of user, or of person who is authorized to act on behalf of the user.

This solvent degreasing annual solvent consumption report
must be submitted no later than 30 days after the end of the year in which the consumption unit applies

Submit the completed and signed solvent degreasing annual solvent consumption report
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