SOLVENT DEGREASING CONSUMPTION UNIT
RETIREMENT NOTICE
[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 retiree, 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 retiree:  (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: 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                        PERC  

name of degreasing process for which consumption units were issued:  (select one only)

                                                                   VAPOUR DEGREASER                                  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