Information about the manufacture or import of toxic substances or products containing them

Schedule 5: Information Relating to the Manufacture or Import of a Toxic Substance or the Import of a Product Containing It

Section 1 - Information respecting the manufacturer or importer

  1. Information on the principal place of business of the manufacturer or importer:
    1. Company name: __________________________
    2. Contact name and title: __________________________
    3. Civic address: __________________________
    4. Postal address: __________________________
    5. Telephone number: __________________________
    6. Fax number (if any): __________________________
    7. Email address (if any): __________________________
  2. Prepared and submitted by (if different from above):
    1. Name of the person authorized to act on behalf of the manufacturer's or importer: __________________________
    2. Title: __________________________
    3. Company name (optional): __________________________
    4. Civic address: __________________________
    5. Postal address: __________________________
    6. Telephone number: __________________________
    7. Fax number (if any): __________________________
    8. Email address (if any): __________________________

Section 2 - Information respecting a toxic substance referred to in column 1 of Part 4 of Schedule 2 that is imported or manufactured and each product containing it that is imported or manufactured in a calendar year

Name of the toxic substance (as listed in the Prohibition of Certain Toxic Substances Regulations, 2012): __________________________
Calendar year: __________________________
In the case of a substance, complete rows A-E.
In the case of a product, complete all rows (A-I).

  1. Substance or name of product: __________________________
  2. Total quantity of the toxic substance manufactured in Canada, and unit of measurement: __________________________
  3. Total quantity of the toxic substance imported into Canada, and its unit of measurement: __________________________
  4. Total quantity of the toxic substance sold in Canada, and unit of measurement: __________________________
  5. Each proposed use of the substance: __________________________
  6. If contained in a product, each proposed use of the product: __________________________
  7. If contained in a product, annual weighted average concentration of the substance and its unit of measurement: __________________________
  8. If contained in a product, analytical method used to determine the concentration in the product: __________________________
  9. If contained in a product, detection limit of the analytical method used to determine the concentration in the product: __________________________

Identify each person in Canada to whom the manufacturer or importer sold the toxic substance or the product:
Substance or name of product: __________________________
Client name: __________________________
Civic address: __________________________
Postal address: __________________________
Telephone number: __________________________
Fax number (if any): __________________________
E-mail address (if any): __________________________
Attach additional sheets if needed

Section 3 - Information respecting the laboratory (laboratories) that determined the concentration of the toxic substance in the product

Identify each laboratory that determined the concentration of the toxic substance in the mixture or product:
Substance or name of product: __________________________
Laboratory name: __________________________
Civic address: __________________________
Postal address: __________________________
Telephone number: __________________________
Fax number (if any): __________________________
E-mail address (if any): __________________________

Section 4 - Certification

I certify that this information is accurate and complete.

_________________________________________________
Date, place

________________________________________________
Signature of the person authorized to submit this report

Disclaimer
This form is provided for information purposes only and may not include all legal requirements. If there is any inconsistency or conflict between the information contained in this document and the Canadian Environmental Protection Act, 1999 and/or the Prohibition of Certain Toxic Substances Regulations, 2012, the official versions of the Act and Regulations take precedence.

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