Management of toxic substances: information related to the use of toxic substances in a laboratory

Schedule 3: Information related to the use of certain toxic substances in a laboratory for analysis, in scientific research or as a laboratory analytical standard

(One submission for each toxic substance)

Section 1 - Information respecting the laboratory

  1. Information on the laboratory where a toxic substance or a product containing it is used or is to be used:
    1. Laboratory 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): __________________________
      Attach additional sheets for multiple laboratories
  2. Prepared and submitted by (if different from above):
    1. Name of the person authorized to act on behalf of the laboratory (laboratories): __________________________
    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 set out in Schedule 1 or 2, and each product containing it that is used or is to be used

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

  1. Anticipated period of use: __________________________
  2. Estimated quantity of the toxic substance to be used in a calendar year and the unit of measurement: __________________________
  3. If contained in a product, name of product: __________________________
  4. If contained in a product, the estimated quantity of the product to be used in the calendar year and the unit of measurement: __________________________
  5. If contained in a product, the estimated concentration of the toxic substance in the product and the unit of measurement: __________________________
  6. Identification of each proposed use and each actual use, as the case may be: __________________________

Section 3 - 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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