SOLVENT DEGREASING CONSUMPTION UNIT
TRANSFER APPLICATION
[See Paragraph 6(3) and Schedule 5 of Solvent Degreasing Regulations]

NOTES:  this form must be used to make a joint application for a consumption unit transfer.
			a separate joint application for the transfer of consumption units must be made for a given solvent and a specific degreasing process.

 STEP 1: Transferor Information

Transferor:	
name of transferor, 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 application on behalf of transferor:  (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- Transferor

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: Transferor Facility Information

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

Facilities: 	

number of facilities included in this application:       __________
	
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: Transferee Information

Transferee:	
name of transferee, 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 application on behalf of transferee:  (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 5: Request for Confidentiality – Transferee

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 6: Transferee Facility Information

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

Facilities: 	

number of facilities included in this application:       __________
	
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 7: Solvent and Degreasing Process Information

Solvent and degreasing process:	

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   

year to which the consumption units apply:        ___________

effective date of consumption unit transfer:  (dd/mm/yy)          _______/________/_______

consumption units issued to the transferor before transfer:               _______________Kg.

transferor’s unexpended consumption units before transfer:               _______________Kg.

unexpended consumption units to be transferred:                                         _______________Kg.

 STEP 8: Signatures

Transferor:

I, ________________________________, (print name of transferor or person who is authorized to act on behalf of transferor) the transferor declare that the information provided in this solvent degreasing consumption unit transfer application is correct.

Date: _____________________

Place: ____________________

Total number of pages in this application:  _____

_______________________________________________
Signature of transferor, or of person who is authorized to act on behalf of the transferor. 

Transferee:

I, _________________________________, (print name of transferee or person who is authorized to act on behalf of transferee) the transferee undertake to use each transferred consumption unit in the same year and in the same degreasing process for which the transferor’s consumption unit was issued; and,
I declare that the information provided in this solvent degreasing consumption unit transfer application is correct.

Date: ____________________

Place: ___________________

___________________________________________________
Signature of transferee, or of person who is authorized to act on behalf of the transferee.

This solvent degreasing consumption unit transfer application
must be submitted for approval before the transfer takes place

Submit the completed and signed solvent degreasing consumption unit transfer application
 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