Declaration of Stakeholder Interest
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Notice with respect to certain high priority petroleum substances on the Domestic Substances List (DSL)
Companies that have an interest in substances described in the Canadian Environmental Protection Act, 1999 (CEPA 1999) section 71 Notice with respect to certain high priority petroleum substances on the Domestic Substances List (DSL) may identify themselves as stakeholders for those substances by completing this form. Stakeholders will be informed of future decisions regarding these substances and may be contacted for further information.
Identification
I have an interest in all substances in the Notice with respect to certain high priority petroleum substances on the Domestic Substances List (DSL)
I am interested in a specific substance or substances in the Notice with respect to certain high priority petroleum substances on the Domestic Substances List (DSL)
Company Name:
_____________________________________________________________________
Federal Business Number[1]:
_____________________________________________________________________
Head Office Address:
_____________________________________________________________________
Canadian Head Office Address (if different from above): _____________________________________________________________________
Contact Name: Mr. Ms. Dr.
_____________________________________________________________________
Title of Contact:
_____________________________________________________________________
Contact Address (if different from Head Office Address):
_____________________________________________________________________
Telephone Number:
( _____ ) _____ - __________
Fax Number:
( _____ ) _____ - __________
Email Address:
_____________________________________________________________________
Request for Confidentiality
Pursuant to section 313 of the Canadian Environmental Protection Act, 1999, I request that the following parts of the information that I am submitting be treated as confidential. (Specify the parts [e.g. sections, tables, attachments, previously submitted unpublished studies or data, etc] of the information that you request be treated as confidential.).
_____________________________________________________________________
I do not request that the information that I am submitting in this declaration be treated as confidential and I consent to it being released without restriction.
Please return this form to the Substances Management Coordinator, Chemical Management Plan
200 Sacré-Coeur Blvd.
Gatineau, Quebec
K1A 0H3
Fax: 819-953-7155
Email: Substances@ec.gc.ca
The questions below are voluntary and interested stakeholders may simply answer the sections which are relevant and for which they currently have the information. This information will help the Government of Canada improve decision making for these substances and ensure all activities are considered before moving forward with further actions regarding these substances.
Provide the CAS RN for the substance or substances of interest: _____________________________________________________________________
_____________________________________________________________________
1. Provide the following, if available:
| CAS RN[1] of the substance (a) |
Name of substance (b) |
Applicable Industrial Function Code (s) (Choose from the list below) (c) |
For each applicable Industrial Function Code, quantity in kg (rounded to the nearest kilogram, if less than 1 000 kg; rounded to the nearest hundred kilograms, if greater than 1 000 kg and less than 10 000 kg; rounded to the nearest thousand kilograms if greater than 10 000 kg and less than 100 000 kg; rounded to the nearest ten thousand kilograms if greater than 100 000 kg) (d) |
NAICS code(s)[2] (e) |
|||
|---|---|---|---|---|---|---|---|
| Manufactured | Imported | Used | Exported | ||||
[1] CAS RN: Chemical Abstracts Service Registry Number. The Chemical Abstracts Service information is the property of the American Chemical Society and any use or redistribution, except as required in supporting regulatory requirements and/or for reports to the Government of Canada when the information and the reports are required by law or administrative policy, is not permitted without the prior, written permission of the American Chemical Society.
[2] A list of six-digit North American Industry Classification System (NAICS) codes is available on Statistics Canada website. Note that the NAICS code(s) Internet address is case sensitive.
2. Provide any unpublished data available on the substance(s) with regards to physical-chemical properties, toxicity, metabolism, degradation, or the releases of the substance:
| CAS RN (a) |
Country of origin (for import) (b) |
Study name for the data (c) |
|---|---|---|
Additional Notes/Comments: (Attach sheets if necessary)
Examples:
- Substance is no longer used by our company;
- Substance was manufactured in large quantities from 2003-2008;
- Substance is imported based on market trends and the use is cyclical;
- Etc.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Industrial Function Codes
| Industrial Function Codes | Title | Description |
|---|---|---|
| U001 | Abrasives | Substances used to wear down or polish surfaces by rubbing against the surface. |
| U002 | Adhesives and sealant substances | Substances used to promote bonding between other substances, promote adhesion of surfaces, or prevent seepage of moisture or air. |
| U003 | Adsorbents and absorbents | Substances used to retain other substances by accumulation on their surface or by assimilation. |
| U004 | Agricultural substances (non-pesticidal) | Substances used to increase the productivity and quality of farm crops. |
| U005 | Anti-adhesive agents | Substances used to prevent bonding between other substances by discouraging surface attachment. |
| U006 | Bleaching agents | Substances used to lighten or whiten a substrate through chemical reaction, usually an oxidative process which degrades the colour system. |
| U007 | Corrosion inhibitors and anti-scaling agents | Substances used to prevent or retard corrosion or the formation of scale. |
| U008 | Dyes | Substances used to impart colour to other materials or mixtures by penetrating into the surface of the substrate. |
| U009 | Fillers | Substances used to provide bulk, increase strength, increase hardness, or improve resistance to impact. |
| U010 | Finishing agents | Substances used to impart such functions as softening, static-proofing, wrinkle resistance, and water repellence. |
| U011 | Flame retardants | Substances used on the surface of or incorporated into combustible materials to reduce or eliminate their tendency to ignite when exposed to heat or a flame. |
| U012 | Fuels and fuel additives | Substances used to create mechanical or thermal energy through chemical reactions, or which are added to a fuel for the purpose of controlling the rate of reaction or limiting the production of undesirable combustion products, or which provide other benefits such as corrosion inhibition, lubrication, or detergency. |
| U013 | Functional fluids (closed systems) | Liquid or gaseous substances used for one or more operational properties in a closed system. This code does not include fluids used as lubricants. |
| U014 | Functional fluids (open systems) | Liquid or gaseous substances used for one or more operational properties in an open system. |
| U015 | Intermediates | Substances consumed in a reaction to produce other substances for commercial advantage. |
| U016 | Ion exchange agents | Substances that are used to selectively remove targeted ions from a solution. This code also includes aluminosilicate zeolites. |
| U017 | Lubricants and lubricant additives | Substances used to reduce friction, heat, or wear between moving parts or adjacent solid surfaces, or that enhance the lubricity of other substances. |
| U018 | Odour agents | Substances used to control odours, remove odours, mask odours, or impart odours. |
| U019 | Oxidizing or reducing agents | Substances used to alter the valence state of another substance by donating or accepting electrons or by the addition or removal of hydrogen to a substance. |
| U020 | Photosensitive substances | Substances used for their ability to alter their physical or chemical structure through absorption of light, resulting in the emission of light, dissociation, discoloration, or other chemical reaction. |
| U021 | Pigments | Substances used to impart colour to other materials or mixtures by attaching themselves to the surface of the substrate through binding or adhesion. |
| U022 | Plasticizers | Substances used in plastics, cement, concrete, wallboard, clay bodies, or other materials to increase their plasticity or fluidity. |
| U023 | Plating agents and surface treating agents | Substances applied to metal, plastic, or other surfaces to alter physical or chemical properties of the surface. |
| U024 | Process regulators | Substances used to change the rate of a reaction, start or stop the reaction, or otherwise influence the course of the reaction. |
| U025 | Processing aids, specific to petroleum production | Substances added to water, oil, or synthetic drilling muds or other petroleum production fluids to control foaming, corrosion, alkalinity and pH, microbiological growth or hydrate formation, or to improve the operation of processing equipment during the production of oil, gas, and other products or mixtures from beneath the earth's surface. |
| U026 | Processing aids, not otherwise covered in this table | Substances used in applications other than the production of oil, gas, or geothermal energy to control foaming, corrosion or alkalinity and pH, or to improve the operation of processing equipment. |
| U027 | Propellants and blowing agents | Substances used to dissolve or suspend other substances and either to expel those substances from a container in the form of an aerosol or to impart a cellular structure to plastics, rubber, or thermo set resins. |
| U028 | Solids separation agents | Substances used to promote the separation of suspended solids from a liquid. |
| U029 | Solvents (for cleaning or degreasing) | Substances used to dissolve oils, greases and similar materials from textiles, glassware, metal surfaces, and other articles. |
| U030 | Solvents (which become part of formulation or mixture) | Substances used to dissolve another substance to form a uniformly dispersed solution at the molecular level. |
| U031 | Surface active agents | Substances used to modify surface tension when dissolved in water or water solutions, or reduce interfacial tension between two liquids or between a liquid and a solid or between liquid and air. |
| U032 | Viscosity adjustors | Substances used to alter the viscosity of another substance. |
| U033 | Laboratory substances | Substances used in a laboratory for chemical analysis, chemical synthesis, extracting and purifying other chemicals, dissolving other substances, and similar activities. |
| U034 | Paint additives and coating additives not otherwise covered in this table | Substances used in a paint or coating formulation to enhance properties such as water repellence, increased gloss, improved fade resistance, ease of application or foam prevention. |
| U061 | Pest control substances | Substances used as active ingredients or formulants in products, mixtures or manufactured items used for directly or indirectly controlling, destroying, attracting or repelling a pest or for mitigating or preventing its injurious, noxious or troublesome effects. |
| U999 | Other (specify) | Substances with an industrial function not otherwise described in this table. A written description must be provided when using this code. |
Footnote
[1] Federal business number is a nine-digit registration number issued by the Canada Revenue Agency (CRA) to Canadian businesses that register for one or more of the following: corporate income tax; importer/exporter account number; payroll.