Declaration of Stakeholder Interest
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Archived
Aromatic Azo- and Benzidine-Based Substances Approach
Companies that have an interest in substances described in the Aromatic Azo- and Benzidine-Based Substances Approach 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 Aromatic Azo- and Benzidine-Based Substances Approach
I am interested in a specific substance or substances in the Aromatic Azo- and Benzidine-Based Substances Approach
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 (Specify the parts [e.g. sections, tables, attachments, previously submitted unpublished studies or data, etc] of the information that you request be treated as confidential.).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.
_____________________________________________________________________
Name (print)
_____________________________________________________________________
Title
_____________________________________________________________________
Signature
_____________________________________________________________________
Date of Signature
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 information on activity with the substance(s):
| (a) CAS RN[1] |
(b) Trade name, generic name or C.I. number |
Quantity of the substance manufactured, imported or used in a calendar year |
(i) Applicable NAICS code(s) |
(j) Additional Notes |
|||||
|---|---|---|---|---|---|---|---|---|---|
| (c) Manufactured (kg) |
(d) Year for quantity reported in column (c) |
(e) Imported (kg) |
(f) Year for quantity reported in column (e) |
(g) Used (kg) |
(h) Year for quantity reported in column (g) |
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[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 information available on the source of the substance(s) (import or domestic):
| (a) CAS RN |
(b) Country of origin (for import) |
(c) Supplier name and address (for import or use) |
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|---|---|---|---|---|---|---|
| Company Name | Full Mailing Address | Contact Person | Phone number | |||
3. Provide information available on the use of the substance(s):
(a)
|
(b) Production process(es) related to the substance listed in (a) |
(c) Type of mixture, product, or manufactured item containing the substance |
Is the mixture, product, or manufactured item intended for: | (f) Is the substance subject to controls in other jurisdictions? (Y/N) (if yes, please specify) |
(g) Additional Notes |
|
|---|---|---|---|---|---|---|
| (d) Use by consumers? (Y/N) |
(e) Use by or for children? (Y/N) |
|||||
4. Provide information available on customer(s):
| (a) CAS RN |
(b) Company name, head office mailing address, contact, telephone number, and email of up to 5 companies in Canada to whom the largest quantity of the substance was sold, either alone, in a mixture, in a product or manufactured item |
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|---|---|---|---|---|---|
| Company Name | Full Mailing Address | Contact Person | Phone number | ||
5. Provide any unpublished data available on the substance(s) with regards to physical-chemical properties, toxicity, metabolism, degradation, or the release of the substance from the final mixture, product, or manufactured item:
| (a) CAS RN |
(b) Description of the data available |
(c) Study name for the data |
|---|---|---|
6. Provide information available on any analogues or alternatives to the substance(s):
| (a) CAS RN |
(b) Alternative or analogue substance CAS RN |
(c) Alternative or analogue substance name or generic name |
(d) List toxicity, metabolic, degradation or physical-chemical data available on the substance identified in column (b) |
(e) Is the alternative substance identified in column (b) being considered for use as a substitute for the substance listed in column (a)? (Y/N) (if yes, please specify) |
(f) Additional Notes |
|---|---|---|---|---|---|
Additional Notes/Comments: (Attach sheets if necessary)
Examples:
- Substance is no longer used by our company;
- Substance is used as a colourant;
- Substance was manufactured in large quantities from 2003-2009;
- Substance is imported based on market trends and the use is cyclical;
- Etc.
| CAS RN | Additional Notes / Comments |
|---|---|
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.