Export of Substances on the Export Control List Regulations guidance document: combined notice of export and export permit application

Please download, fill, print and send back the PDF version of the above form. This HTML version is provided for on-line reading.

Part 1: general information

Exporter

Name of exporter:
Name of duly authorized representative:
Address:

Telephone number:
Fax number:
Email address:

Importer

Name:
Address:

Telephone number:
Fax number:
Email address:

For Environment Canada use

Part 2: identification of the substance or the product that contains the substance

1. Name of substance as it appears on the Export Control List (schedule 3 of the Canadian Environmental Protection Act, 1999): _______
2. Common name, if known: _______
3. Trade name, if known: _______
4. CAS registry number: _______
5. Commodity code of the substance that is obtained from the Harmonized Commodity Description and Coding System: _______

Part 3: export information

6. Country of destination: _______
7. Expected date of export: _______
8. Estimated quantity of the substance to be exported: ___ kg
9. Purpose of export:
    [  ] Destruction
    [  ] Industrial chemical use
    [  ] Pesticidal use
    [  ] Other use

10. If the substance is contained in a manufactured product indicate:

1. The name of the product:
2. Concentration of substance in the product:

11. List the customs office through which the export is expected to exit Canada, if known: _______
12. List any countries through which the substance will transit, if known: _______
13. Proposed number of exports for the calendar year, if known: _______

You must attach the Safety Data Sheet for the substance being exported, or if applicable, for the product that contains the substance.

Part 4: exports subject to the Stockholm Convention for substances listed on part 2 or part 3 of the Export Control List

For all substances notified in part 2 of this form which are found on part 2 or part 3 of the Export Control List and listed in annex a or b of the Stockholm Convention and in force for Canada, please complete the following:

Name of substance: ____________________

1. Specific exemption or acceptable purpose applicable to the substance being exported (if applicable): _______
   
2. Is the substance being exported for environmentally sound disposal in accordance with paragraph 1(d) of article 6 of the Stockholm Convention?
     [  ] Yes  [  ] No  If yes, please indicate:
       Facility name and civic address: _______________
       Method of disposal: _______________
   
3. Is the substance being exported for use:
   1. in a laboratory for analysis [  ] Yes  [  ] No
   2. in scientific research [  ] Yes  [  ] No; or
   3. as a laboratory analytical standard? [  ] Yes  [  ] No
4. Is the substance being exported contained in a manufactured article? [  ] Yes  [  ] No
   If yes,
   1. Is the substance incidentally present in trace amounts? [  ] Yes  [  ] No
   2. Was the article containing the substance manufactured on or before the coming into force for Canada of a provision of the Stockholm Convention prohibiting, under annex a, or restricting under annex b, the production or use of that substance? [  ] Yes  [  ] No
      If yes, indicate the date of manufacture of article: _______________

(Repeat part 3 for each substance notified in part 2 of this form that is listed on annex a or b of the Stockholm Convention and on part 2 or part 3 of the Export Control List)

Attach supplementary sheets as necessary

The regulations require notification to be provided at least 15 days (at least 7 days if the person holds a permit to export the substance issued under paragraph 185(1)(b) of the act or under the Ozone-depleting Substances and Halocarbon Alternatives Regulations) prior to the first export indicated on the notice. This form may be used to provide more than one notification under these regulations. Exporters are required to notify the Minister of any corrections to the information provided in the notice within 30 days after learning of them.

Send the notice by email, facsimile or by mail to:
Minister of the Environment
c/o Chemical Production Division
Environment and Climate Change Canada
351 Saint-Joseph Blvd 11th floor
Gatineau QC
Facsimile: 819-938-4218
ec.substancedexportationcontrolee-exportcontrolledsubstance.ec@canada.ca

Attach supplementary sheets as necessary

Section 10 of the regulations describes exports that require the exporter to hold a valid export permit issued under the regulations. A copy of the permit must be included with these exports in addition to the labelling prescribed by section 21.

A minimum of 15 days (7 days (if the person holds a permit to export the substance issued under paragraph 185(1)(b) of the act or under the Ozone-depleting Substances and Halocarbon Alternatives Regulations) prior notice of export is mandatory under section 5 of the regulations for all exports, including those requiring an export permit.

Send the application by email, facsimile or by mail to:
Minister of the Environment
c/o Chemical Production Division
Environment and Climate Change Canada
351 Saint-Joseph Blvd 11th floor
Gatineau QC
Facsimile: 819-938-4218
ec.substancedexportationcontrolee-exportcontrolledsubstance.ec@canada.ca

Part 5: declaration

I understand that I, as the exporter, assume full responsibility for the removal of the substance from the country of destination and any related costs, including the transportation, care, control and storage of the substance, in the event that the exported substance is in contravention of any conditions set out in the export permit or if the export takes place after the export permit has expired or has been cancelled.

I declare that the above information is accurate and complete. I understand that information in this application may be released to the country of destination.