Annual solvent consumption report form: solvent degreasing regulations

[see paragraph 7 (a) and schedule 6 of solvent degreasing regulations]

Note: this form must be used to make the annual solvent consumption report.

Year for which annual solvent consumption report is being made: _____

Step 1: user information

User:

Name of user, company or corporation:

Civic address of principal place of business:
number and street:
city:
province:
postal code:

postal address of principal place of business (if different from the civic address):
number and street:
city:
province:
postal code:

telephone number (include area code): ( )
fax number (if any - include area code): ( )
e-mail address (if any):

person authorized to submit notice on behalf of user (if applicable):

Name:
title:
name of company:

Civic address of principal place of business:
number and street:
city:
province:
postal code:

Postal address of principal place of business (if different from the civic address):
number and street:
city:
province:
postal code:

telephone number (include area code): ( )
fax number (if any - include area code): ( )
e-mail address (if any):

Step 2: request for confidentiality

Note: indicate if a request for confidentiality is being made under section 313 of the canadian environmental protection act (cepa), 1999 and the reason for the request.

Do you request confidentiality under section 313 of cepa 1999? Yes or no. State reason.

Step 3: user facility information

Note: if more than five (5) facilities, attach additional copies of this page.

Facilities:

Number of facilities included in this report: ______

Civic address of facility 1:
number and street:
city:
province:
postal code:

Postal address of facility 1 (if different from the civic address):
number and street:
city:
province:
postal code:

Civic address of facility 2:
number and street:
city:
province:
postal code:

Postal address of facility 2 (if different from the civic address):
number and street:
city:
province:
postal code:

Civic address of facility 3:
number and street:
city:
province:
postal code:

Postal address of facility 3 (if different from the civic address):
number and street:
city:
province:
postal code:

Civic address of facility 4:
number and street:
city:
province:
postal code:

Postal address of facility 4 (if different from the civic address):
number and street:
city:
province:
postal code:

Civic address of facility 5:
number and street:
city:
province:
postal code:

Postal address of facility 5 (if different from the civic address):
number and street:
city:
province:
postal code:

Step 4: solvent and degreasing process information

Notes:

Separate solvent and degreasing process information must be provided for each given solvent and specific degreasing progess.
Make and attach additional copies of pages where more than one given solvent and specific degreasing process is reported or additional space is required.
All quantities are to be reported in kilograms.

Solvent and degreasing process:

Name of solvent (select one only): tce or perc
name of degreasing process (select one only): vapour degreaser or cold degreaser
average annual consumption (paragraph 4(1)(e)): ___ kg
consumption units issued (paragraph 4(5)): ___ kg
quantity in opening inventory: ___ kg
quantity supplied by sellers (from step 5): ___ kg
quantity supplied by others (from step 6): ___ kg
quantity transferred from other on-site uses (from step 7): ___ kg
quantity transferred from other off-site uses (from step 8): ___ kg
quantity reclaimed or recycled on-site: ___ kg
quantity transferred on-site for other uses (from step 9): ___ kg
quantity transferred off-site for other uses (from step 10): ___ kg
quantity sold to others (from step 11): ___ kg
quantity transferred to others (from step 12): ___ kg
quantity in closing inventory: ___ kg

Step 5: quantity of solvent supplied by sellers (if applicable)

Date supplied:
seller name:
civic address:
quantity (kg):
total (kg):