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What you need to know about the Products Containing Mercury Regulations: appendices

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Appendices

Appendix 1: Sample permit application form

Note: This is not a mandatory form. It is intended to provide guidance.

Products Containing Mercury Regulations

Information to be contained in an application for a permit

Is this a submission of additional information requested by the Minister?
◻ Yes   ◻ No

If yes, complete parts 1, 5 and any other parts of this application where additional information was requested. Previously reported information that is unchanged need not be resubmitted.

Is this permit a renewal application?   ◻ Yes   ◻ No

If yes, indicate the number of the permit _______________________









For Environment Canada use


 

1. Applicant information

Name of applicant (e.g., corporation):

________________________________________
Telephone:

__________________

 

Civic and postal addresses:

________________________________________

________________________________________

________________________________________
Fax (if any):

__________________

Email (if any):

___________________________________

 

Name and title of duly authorized representative:

________________________________________
Telephone:

__________________

 

Civic and postal addresses:

________________________________________

________________________________________

________________________________________
Fax (if any):

__________________

Email (if any):

___________________________________

 

2. Information respecting the product for which the application is made

Common or generic name Trade name
(if any)		 Total quantity of mercury in the product (mg) Estimated quantity of products to be manufactured per calendar year
(number)		 Estimated quantity of products to be imported per calendar year
(number)
         
   ◻

I am enclosing an identification and description of each known use of the product.

 

3. Declaration respecting the provision of information

   ◻

I am enclosing evidence that there are no technically or economically feasible alternatives to or substitute for the product that achieve a similar result as would be achieved by using the product containing mercury, and have a less harmful effect on the environment or on human health than the product containing mercury.

 

   ◻

I am enclosing a copy of the plan prepared identifying and describing the measures that will be taken by the applicant to minimize or eliminate any harmful effect that the mercury contained in the product has or may have on the environment and human health, including measures to ensure that the mercury is handled safely and is not released into the environment during the normal use of the product and at the end of its useful life.

 

   ◻

The plan will be fully implemented within 30 days after the day on which the permit is issued.

 

4. Civic and postal addresses of the location where information, supporting documents and the certification are kept

Civic and postal addresses:

______________________________________________________
______________________________________________________
______________________________________________________

 

5. I declare that the information in this application and in all enclosed documents is accurate and complete.

 

__________________________________
Date, place
____________________________________________
Signature of applicant or duly authorized representative

Appendix 2: Definitions

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