SOLVENT DEGREASING ANNUAL SOLVENT SALES REPORT
[See Paragraph 8(a) and Schedule 7 of Solvent Degreasing Regulations]

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

Year for which annual solvent sales report is being made: __________

 STEP 1: Seller Information

Seller:	
name of seller, 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 seller:  (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: Seller 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 Information

NOTES:   solvent, recycled solvent and reclaimed solvent are to be reported separately.
all quantities are to be reported in kilograms.
make and attach additional copies of pages where additional space is required.

Solvent sold:  (if applicable)		

date
of
 sale

purchaser’s name

civic address	

TCE
(Kg)	

PERC
(Kg)	

					

					

					

					

					

					

					

total

Solvent returned by purchasers:  (if applicable)	

date
of
return

purchaser’s name	

civic address	

TCE
(Kg)	

PERC
(Kg)	

					

					

					

					

					

					

					

total

 STEP 4: Solvent Information (con’d)

Recycled solvent sold:  (if applicable)		

date
of
sale

purchaser’s name

civic address	

TCE
(Kg)	

PERC
(Kg)	

					

					

					

					

					

					

					

					

total

Recycled solvent returned by purchasers:  (if applicable)	

date
of
return

purchaser’s name	

civic address	

TCE
(Kg)	

PERC
(Kg)	

					

					

					

					

					

					

					

					

total

 STEP 4: Solvent Information (con’d)

Reclaimed solvent sold:  (if applicable)		

date
of
sale

purchaser’s name

civic address	

TCE
(Kg)	

PERC
(Kg)	

					

					

					

					

					

					

					

					

total

Reclaimed solvent returned by purchasers:  (if applicable)	

date
of
return

purchaser’s name	

civic address	

TCE
(Kg)	

PERC
(Kg)	

					

					

					

					

					

					

					

					

total

 STEP 5: Signature

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

Date: _____________________

Place: ____________________

Total number of pages in this report:  _____

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

This solvent degreasing annual solvent sales report
must be submitted no later than 30 days after the end of the year in which the sale occurs

Submit the completed and signed solvent degreasing annual solvent sales 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