New substances notification reporting form

Table of Content

Introduction

This form is to be used for fulfilling the information requirements prescribed in the New Substances Notification Regulations (Organisms) [NSNR (Organisms)] of the Canadian Environmental Protection Act, 1999 (CEPA 1999) when notifying a micro-organism. If you are notifying an organism other than a micro-organism, please use the New Substances Notification (NSN) Reporting Form for organisms other than a micro-organism.

The NSN package must be submitted to:

Mailing Address:
Executive Director, Program Development and Engagement Division
Department of the Environment
Ottawa ON, K1A 0H3

Courier Deliveries:
Executive Director, Program Development and Engagement Division
Department of the Environment
8th Floor, Fontaine Building
Gatineau QC, J8Y 3Y5

Departmental Use Only

NSN Reference No.:

_________________________

Date Received:

_________________________

Mail Log:

_________________________

Total number of pages:

_________________________

Instructions for Completing the Notification Form

The NSN Reporting Form serves as an aid for complying with the NSNR (Chemicals and Polymers) of CEPA 1999.  Notifiers may reproduce this form, or portions thereof, for notification purposes. The form is also available electronically from the New Substances website.

Additional explanations necessary for fulfilling prescribed information requirements and completing this notification form are included in the Guidelines for the Notification and Testing of New Substances: Chemicals and Polymers. Hard copies of the Guidelines may be obtained from Environment Canada, for a fee, by contacting the Substances Management Information Line at 1-800-567-1999 (toll free in Canada), or (819) 938-3232 for callers outside of Canada; or via Substances@ec.gc.ca. The Guidelines are also available on the aforementioned New Substances ­website.

This form is divided into four sections: parts A to D. Part A is used for administrative and substance identity information while Part B and Part C are for technical information. Part D is used for any additional information that may be provided with the notification.

Before completing Part B or Part C of the form, you should ensure that you are providing information appropriate for the quantity and category of substance you intend to manufacture or import (refer to section 3.4 of the Guidelines). Part B contains four sections: (1) Physical and Chemical Information Requirements; (2) Ecotoxicity Information Requirements; (3) Health Toxicity Information Requirements; and (4) Genotoxicity Information Requirement. Part C contains one section: Biochemical or Biopolymer Information Requirements. Part B contains five columns and Part C contains four columns which consist of: Submit with Schedule; Data Codes; Value & Conditions; Attachment Number; and Confidential Information. Explanations of the use of these columns are provided on page 2 of this form. Part D contains two sections: (1) Other Requirements; and (2) Additional Information and Attachments.

Also included are two appendices. Appendix I is for Manufacture, Import, Use, Exposure and Release Information (Known and Anticipated) and Appendix II is the New Substances Fee Payment Form.

Ce formulaire est disponible en français, sur demande, en communiquant avec La ligne d’information de la gestion des substances au 1-800-567-1999 (sans frais au Canada) ou au (819) 938-3232 (de l'étranger). Le formulaire est aussi disponible en ligne sur le Site Web des substances nouvelles.

Data Codes, Attachments and Confidential Information

In addition to the list of information requirements, Part B contains five columns and Part C contains four columns which consist of: Submit with Schedule; Data Codes; Value & Conditions; Attachment Number; and Confidential Information. The following explains the use for each of these columns.

Submit with Schedule: This is a quick reference column that allows you to determine, at a glance, which schedule requires the information to be provided. Take note of the footnotes for certain exceptions and conditions associated with certain data elements. It is important to note that if lower schedule notifications are not submitted, the information prescribed in them is still required to be submitted with the higher schedule notification.

Data Codes: A Data Code is a reference to indicate: whether data are provided; the type of data being submitted; or whether a request for waiver of information is being submitted. The Data Codes with explanatory notes are:

  • D = test data on notified substance
    This code is used when the data provided were generated on the notified substance using protocols consistent with these listed in Tables 8-1 to 8-4 of the Guidelines. This code is to be used even if the information is provided under the Additional Information Requirements of the schedules (refer to section 6.5 of the Guidelines).
  • A = alternative procedures
    This code is used when the data provided were generated using: (1) an alternative test protocol; (2) structure-activity relationships (SARs), including surrogate data and quantitative structure-activity relationships (QSARs); or (3) other calculation methods (refer to section 8.4.3 of the Guidelines). This code is to be used even if the information is provided under the Additional Information Requirements of the schedules (refer to section 6.5 of the Guidelines).
  • W = waiver requested
    This code is used when the data required are being requested to be waived. Requests for a waiver of prescribed information must be accompanied by justifications that satisfy any of the waiver criteria listed in subsection 81(8) of the Act (refer to section 8.7 of the Guidelines).
  • N/A = not applicable
    This code is used if the NSNR specify that the provision of information is not required under certain conditions. For example, the adsorption-desorption screening test data are not required when water solubility is less than 200 µg/L. This code cannot be used as an abbreviation for "not available."
  • NR = not required
    This code is used when the information has not been provided and is not required for that specific schedule of the NSNR.
  • P = previous NSN reference number / Pre-notification Consultation (PNC) reference number or notice under section 70 of the Act
    This code is to be used when the notifier has already provided the information to the New Substances program in a previous NSN package, a previous PNC request and/or a notice under section 70 of the Act. The applicable NSN, PNC or notice under section 70 reference number must be entered in the Attachment column.

Value and Conditions: Although complete physical-chemical data must be submitted in test reports (physical state and whether the notified substance is formulated for dispersal in water excepted), the notifier must enter the value and conditions in the appropriate space provided. This information will assist the notifier in organizing data for use; in requesting waivers of information; in justifying cases when data are not applicable; and in discussing notifications with New Substances program officials. Physical-chemical values and corresponding conditions may be expressed in units cited within the laboratory report. In the event that the data are only available in degrees Fahrenheit, the notifier must strike out the °C symbol printed in the entry and replace it with the °F symbol.

Attachment Number: The notifier must clearly indicate a reference for accompanying documents (e.g., Attachment 6) so that they may be readily located within the NSN package. Attachments include: justifications for waivers of information; reports of experimental procedures; reports of test results; rationale for alternative data; results and validation of modeling studies; rationale for why information is considered "not applicable"; and information supplemental to a request for confidentiality.

Confidential Information: Notifiers must check the appropriate box to indicate that the information provided is considered confidential (i.e., check "Y" to indicate that "Yes" the information is considered confidential or check “N” to indicate that "No" the information is not confidential). If the information provided is considered confidential, the notifier must provide, in the NSN package, the supplementary information detailed in section 7.2 of the Guidelines.

Part A - Administrative and Substance Identity Information

(refer to sections 6.2.1.1 to 6.2.1.6 of the Guidelines)

A.1 - Certification Statement

I hereby certify to the best of my knowledge that all information provided in this form, as well as any attachments to the form, are accurate and complete, and that the information for which confidentiality is claimed meets the criteria for determining confidentiality as outlined in section 7 of the Guidelines.

Name and title of the person authorized to act on behalf of the corporation of block A.2 or A.3:

______________________________________________________

Signature:

______________________________________________________

Date (YYYY/MM/DD):

______________________________________________________

Name and title of the person in Canada authorized to act on behalf of the corporation of block A.4 (if applicable):

______________________________________________________

Signature:

______________________________________________________

Date (YYYY/MM/DD):

______________________________________________________

Preferred Language of Correspondence: English, French

Preferred Mode of Communication for Correspondence: Mail, Facsimile (non-secure)

A.2 - Corporate Headquarters of the Canadian Manufacturer or Importer (Principal Place of Business in Canada)

(if the importer is not located in Canada, skip to block A.3)

Company Name:

______________________________________________________

Email:

______________________________________________________

Street:

______________________________________________________

City:

______________________________________________________

Province:

______________________________________________________

Postal Code:

______________________________________________________

Telephone No.: (______) - ______________

Facsimile No.: (______) - ______________

A.3 - Corporate Headquarters of the Non-resident Importer

(if A.3 is applicable, also complete block A.4)

Company Name:

______________________________________________________

Email:

______________________________________________________

Street:

______________________________________________________

City:

______________________________________________________

State/Country:

______________________________________________________

Zip / Postal Code:

______________________________________________________

Telephone No.: (______) - ______________

Facsimile No.: (______) - ______________

A.4 - Canadian Agent

(only needed if block A.3 is applicable)

Company Name:

______________________________________________________

Email:

______________________________________________________

Street:

______________________________________________________

City:

______________________________________________________

Province:

______________________________________________________

Postal Code:

______________________________________________________

Telephone No.: (______) - ______________

Facsimile No.: (______) - ______________

A.5 - Foreign Supplier

(only needed if the technical information in Part B is provided by a third party)

Company Name:

______________________________________________________

Email:

______________________________________________________

Street:

______________________________________________________

City:

______________________________________________________

State/Country:

______________________________________________________

Zip / Postal Code:

______________________________________________________

Telephone No.: (______) - ______________

Facsimile No.: (______) - ______________

A.6 - Technical Contact

(name of a person who can assist in the resolution of issues pertaining to the information provided)

Person’s Name/Title:

______________________________________________________

Email:

______________________________________________________

Street:

______________________________________________________

City:

______________________________________________________

Province / State / Country:

______________________________________________________

Zip / Postal Code:

______________________________________________________

Telephone No.: (______) - ______________

Facsimile No.: (______) - ______________

A.7 - Proposed Site of Manufacture in Canada / Proposed Port of Entry into Canada

Company Name / Port of Entry:

______________________________________________________

Contact Name:

______________________________________________________

Street:

______________________________________________________

City:

______________________________________________________

Province:

______________________________________________________

A.8 - Previous NSN Reference Number / PNC Reference Number

______________________________________________________

Date (YYYY/MM/DD):

______________________________________________________

A.9 - Fee Provided (if applicable)

$ _____________
(Please complete Appendix II - New Substances Fee Payment Form)

A.10 - Manufacture/Import

Manufacture
Import
Manufacture and Import

A.11 - Amount

(indicate the quantity that triggered this notification)

100 kg
1000 kg
10 000 kg
50 000 kg

A.12 - Date that the Amount in Block A.11 is Expected to be Exceeded

Date (YYYY/MM/DD):

______________________________________________________

A.13 - Substance Information

(check all that apply)

Present on the Non-domestic Substances List (NDSL) or Confidential NDSL
NDSL Accession Number: _________________

Chemical
Biochemical
Biopolymer
Polymer

Right arrow

All reactants specified on the Domestic Substances List (DSL) or NDSL
Meets the Reduced Regulatory Requirement (RRR) polymer criteria





Special Category:

Research & Development
Contained Export Only
Contained Site Limited Intermediate

A.14 - Schedule Number

Special Category: 1- 2 - 3
Chemical / Biochemical: 2 - 4 - 5 - 6
Polymer / Biopolymer: 2 - 9 - 10 - 11

A.15 - Anticipated, Historical and Other Likely Uses of the Substance

This substance is used solely for an application subject to the Food and Drugs Act.1

______________________________________________________

A.16 - Anticipated Annual Quantity to be Manufactured and/or Imported

______________________________________________________

A.17 - Confidentiality Requests

Y or N - Corporation
Y or N - Manufacture
Y or N - Import
Y or N - Amount
Y or N - Substance Identity

A.18 - Information Sharing Agreement Authorization

I hereby grant the Minister of the Environment permission to release the name, address and phone number of the technical contact indicated in block A.7 of this form to any person who has provided the Minister of the Environment with: (1) documentation of intent to manufacture or import the substance described in block A.20 of this form; and (2) a statement granting the Minister of the Environment permission to release the name, address and phone number of their technical contact.

Name and title:

______________________________________________________

Signature:

______________________________________________________

Date (YYYY/MM/DD):

______________________________________________________

A.19 - Chemical Abstract Service (CAS) Registry Number and/or Enzyme Commission Number2

______________________________________________________

A.20 - Chemical Name of the Substance

Nomenclature:
International Union of Pure and Applied Chemistry (IUPAC)
Chemical Abstract Service (CAS)
International Union of Biochemistry and Molecular Biology (IUBMB)

______________________________________________________

A.21 - Proposed Masked Name

(if the chemical name of the substance is claimed confidential)

______________________________________________________

Multiple Masking: _________________

Justification Enclosed
Attachment Number: _________________

A.22 - Known Trade Name or Synonyms of the Chemical Name of the Substance

______________________________________________________

A.23 - Structural Formula of the Substance

______________________________________________________

RRR Polymer: _________________

Reaction Scheme Enclosed
Attachment Number: _________________

A.24 - Molecular Formula

______________________________________________________

A.25 - Gram Molecular Weight

______________________________________________________

A.26 - Monomers and Reactants with their Concentration

Substance Name:

______________________________________________________

CAS Registry Number:

__________________

% by weight:

__________________
100%

A.27 - Additives, Stabilizers and Solvents with their Concentration

Substance Name:

______________________________________________________

CAS Registry Number:

__________________

% by weight:

__________________

A.28 - Impurities with their Concentration

Substance Name:

______________________________________________________

CAS Registry Number:

__________________

% by weight:

__________________

A.29 - Degree of Purity in its Technical Grade Composition

__________________

A.30 - Material Safety Data Sheet (MSDS)

Enclosed
Attachment Number: _________________

Part B - Technical Information

(refer to sections 6.3.1.1 to 6.3.1.15 of the Guidelines)

B.1 - Physical & Chemical Information Requirements
Requirements Submit with
Schedule
Data Code Value & Conditions Attachment Number Confidential Information
Melting Point 5, 6   ____ °C   Y or N
Boiling Point 5, 6   ____ °C   Y or N
Density 5, 6   ____ g/cm @ ____ °C   Y or N
Vapour Pressure 5, 6   ____ @ ____ °C   Y or N
Water Solubility 5, 6   ____ g/L @ ____ °C   Y or N
Octanol/Water Partition Coefficient 5, 6, 10, 11       Y or N
Ready Biodegradation 5, 6, 11       Y or N
Spectroscopy:
IR
UV
NMR
Mass
6       Y or N
Adsorption-Desorptiona 6       Y or N
Hydrolysis as a Function of pH[a] 6, 10, 11       Y or N
Physical State 3, 10, 11       Y or N
Formulated for Dispersal in Water 3, 10, 11   Y or N   Y or N
Water Extractability 10, 11   ____ %   Y or N
Number-average Molecular Weight (Mn) 3, 9, 10, 11       Y or N
Weight Percent less than 1000 Daltons 3b, 9, 10, 11       Y or N
Weight Percent less than 500 Daltons 3[b], 9, 10, 11       Y or N
B.2 - Ecotoxicity Information Requirement a
Requirements[a] Submit with
Schedule
Data Code Value & Conditions Attachment Number Confidential Information
Acute Toxicity:
Fish
Daphnia
Algal
5, 10       Y or N
Other Acute Toxicity (check two that apply)
Fish
Daphnia
Algal
6, 11       Y or N
B.3 - Health Toxicity Information Requirements
Requirements Submit with
Schedule
Data Code Value & Conditions Attachment Number Confidential Information
Acute Mammalian Toxicity
Oral
Dermal
Inhalation
5, 10, 11       Y or N
Other Acute Mammalian Toxicity
Oral
Dermal
Inhalation
6       Y or N
Information Sufficient to Assess Skin Irritation 6, 11       Y or N
Skin Sensitization 6, 11       Y or N
Repeated Dose Mammalian Toxicitya
Oral
Dermal
Inhalation
6, 11       Y or N
B.4 - Genotoxicity Information Requirements
Requirements Submit with Schedule Data Code Value & Conditions Attachment Number Confidential Information
In Vitro Test for Gene Mutationsa 5, 6, 11       Y or N
In Vitro Mammalian Test for Chromosomal Aberrations[a] 6, 11       Y or N
In Vivo Mammalian Test for Chromosomal Aberration or Gene Mutations[a] 6, 11       Y or N

Part C - Biochemical or Biopolymer Information Requirements

(refer to sections 6.4.1 to 6.4.5 of the Guidelines)

C.1 - Additional Information Required for Biochemicals or Biopolymers
Requirements Submit with
Schedule
Data Code Attachment Number Confidential Information
Identification 1, 3, 4, 5, 6, 9, 10, 11     Y or N
Source and History 1, 3, 4, 5, 6, 9, 10, 11     Y or N
Adverse Environmental or Human Health Effects 1, 3, 4, 5, 6, 9, 10, 11     Y or N
Concentration of the Viable Production Organism 1a, 3[a], 4, 5, 6, 9, 10, 11     Y or N
Methods Used to Separate the Production Organism 1b, 3[b], 5, 6, 10, 11     Y or N
Identification of Encoded Productsc 1[a], 3[a], 5, 6, 10, 11     Y or N
Description of Biological Activity[c] 1[a], 3[a], 5, 6, 10, 11     Y or N
Catalytic Functionsd 1[a], 5, 6     Y or N
Substrate Specificity[d] 1[a], 5, 6     Y or N
Optimum pH and Temperature[d] 1[a], 5, 6     Y or N
Catalytic Constants KMr and Kcatr[d] 1[a], 5, 6     Y or N
Cofactors[d] 1[a], 5, 6     Y or N
Enzymatic Activity[d] 1[a], 5, 6     Y or N

Part D - Additional Information Requirements

(refer to sections 6.5.1.1 to 6.5.2.1 of the Guidelines)

D.1 - Other Requirements
Requirements Submit with
Schedule
Attachment Number
Other agencies notified, the agency’s file number and the outcome. 1, 3, 4, 5, 6, 9, 10, 11  
Other information and test data in the possession of the manufacturer or importer 1, 3, 4, 5, 6, 9, 10, 11  
D.2 - Additional Information and Attachments
Attachment Name Attachment Number Confidential Information
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N
    Y or N

Appendix I - Manufacture, Import, Use, Exposure and Release Information (Known and Anticipated)

A - Manufacture and/or Importation Information

(see section 6.6.1 of the Guidelines)

A.1 - Canadian Manufacture and Processing Information3

(section 6.6.1.1)

Confidential?Y or N

Manufacturing process description:

______________________________________________________

______________________________________________________

Flow diagram of process (provide attachment):

Enclosed
Attachment Number: _________________

Steps in operations:

______________________________________________________

______________________________________________________

A.2 - Anticipated Annual Production / Import Quantities of Notified Substance4

(section 6.6.1.2)

Confidential?Y or N

Anticipated Annual Production / Import Quantities of Notified Substance
  Amount Quantity during first 12 months (kg/yr) Maximum quantity in any 12-month period during first 3 years (kg/yr)
Manufactured within Canada (if any):    
Imported into Canada (if any):    
For export (if any):    

List the three sites in Canada where the greatest quantity of the substance to be manufactured or imported by the notifier is anticipated to be used or processed, if known5:

  • Site 1: ______________________________________________________

  • Site 2: ______________________________________________________

  • Site 3: ______________________________________________________

Estimated quantity for each site

  • Site 1: ______________________________________________________

  • Site 2: ______________________________________________________

  • Site 3: ______________________________________________________

B - Uses of the Substance

(see section 6.6.2 of the Guidelines)

B.1 - Anticipated[4], Historical[4] and Other Likely Usesa for the Substance

(see section 6.6.2.1 of the Guidelines)

Confidential? Y or N

1) Provide anticipated, historical or any other likely use of the notified substance or type of product containing the notified substance:

______________________________________________________

______________________________________________________

And to the degree known :

  • a) The function/application for this use:

    ______________________________________________________

  • b) The industrial/commercial/consumer application for this use:

    ______________________________________________________

  • c) If the use is highly dispersive, non-dispersive, contained, consumed or other:

    ______________________________________________________

  • d) The maximum annual quantity of notified substance for this use (kg/yr):

    ______________________________________________________

  • e) For contained site-limited intermediate substances, the location of use6:

    ______________________________________________________

2) Provide anticipated, historical or any other likely use of the notified substance or type of product containing the notified substance:

______________________________________________________

______________________________________________________

And to the degree known :

  • a) The function/application for this use:

    ______________________________________________________

  • b) The industrial/commercial/consumer application for this use:

    ______________________________________________________

  • c) If the use is highly dispersive, non-dispersive, contained, consumed or other:

    ______________________________________________________

  • d) The maximum annual quantity of notified substance for this use (kg/yr):

    ______________________________________________________

  • e) For contained site-limited intermediate substances, the location of use[6]:

    ______________________________________________________

3) Provide anticipated, historical or any other likely use of the notified substance or type of product containing the notified substance:

______________________________________________________

______________________________________________________

And to the degree known :

  • a) The function/application for this use:

    ______________________________________________________

  • b) The industrial/commercial/consumer application for this use:

    ______________________________________________________

  • c) If the use is highly dispersive, non-dispersive, contained, consumed or other:

    ______________________________________________________

  • d) The maximum annual quantity of notified substance for this use (kg/yr):

    ______________________________________________________

  • e) For contained site-limited intermediate substances, the location of use[6]:

    ______________________________________________________

B.2 - Concentration in Products

(see section 6.6.2.2 of the Guidelines)

Confidential? Y or N

Anticipated concentration of notified substance in notifier’s product (specify units)7:

______________________________________________________

Concentration (or range of concentrations) of notified substance as imported, if known:

______________________________________________________

Anticipated concentration of notified substance in end-use products, if known (specify units)8:

______________________________________________________

B.3 - Anticipated to be Used in Products Intended for Use by or for Children[5]

(see section 6.6.2.3 of the Guidelines)

Confidential?Y or N

Check one (see below):Y or N

If yes, describe what types of products these may be:

______________________________________________________

______________________________________________________

C - Human Exposure Information Requirements

(see section 6.6.3 of the Guidelines)

C.1 - Whether the Public is Anticipated to be Significantly Exposed to the Substance9

(see section 6.6.3.1 of the Guidelines)

Confidential? Y or N

If yes, describe whether the substance is present in products wherein the public is anticipated to be significantly exposed to the substance, taking into consideration factors including the use, duration, frequency of use, concentration of the substance in the product and circumstances of exposure that may limit direct human exposure:

______________________________________________________

______________________________________________________

______________________________________________________

If not, provide below the information substantiating that the public is not anticipated to be significantly exposed:

______________________________________________________

______________________________________________________

______________________________________________________

C.2 - Anticipated Degree of Direct Human Exposure10

(see section 6.6.3.2 of the Guidelines)

Confidential?Y or N

Describe the anticipated degree of direct human exposure to the notified substance, especially for the general public, including concentration, duration, frequency, and circumstances of exposure. Describe conditions of use that may limit direct human exposure:

______________________________________________________

______________________________________________________

______________________________________________________

Routes of exposure at each stage, if known:

______________________________________________________

______________________________________________________

______________________________________________________

Estimates of number of persons that may be exposed, if known:

______________________________________________________

______________________________________________________

______________________________________________________

D - Environmental Exposure Information

(see section 6.6.4 of the Guidelines)

D.1 - Components of the Environment into which Release is Anticipated11

(see section 6.6.4.1 of the Guidelines)

Confidential? Y or N

Provide an identification of the components of the environment into which the substance is anticipated to be released:

______________________________________________________

______________________________________________________

______________________________________________________

Stages in the import process where emissions or discharges to the environment may occur, if applicable:

______________________________________________________

Quantities and concentration of release:

______________________________________________________

Physical form of the substance for each location into which the substance will be released and the anticipated frequency, duration and rate of release, if applicable:

______________________________________________________

______________________________________________________

Estimate of the fugitive emissions, if known:

______________________________________________________

Description of the waste management practices designed to prevent or minimize the release of the substance in effluents and emissions, if applicable:

______________________________________________________

______________________________________________________

Amount of substance, in effluents and emissions, expected to be released to the environment, including average and peak concentrations, if applicable:

______________________________________________________

______________________________________________________

Describe the contingency plan to deal with unintended releases from the manufacturing processes; if applicable:

______________________________________________________

______________________________________________________

Provide information on any potential releases from commercial or consumer products or potential releases during processing by domestic customers, if known:

______________________________________________________

______________________________________________________

D.2 - Anticipated Releases of the Substance into Municipal Wastewater Systems12

(see section 6.6.4.2 of the Guidelines)

Confidential? Y or N

Check one:
Direct to the Municipal Wastewater Treatment Facility; or
Go directly into surface waters

Total amount (kg/day) anticipated to be discharged:

______________________________________________________

Name of municipal treatment facility:

______________________________________________________

Address of municipal wastewater treatment facility, if applicable:

______________________________________________________

Name of receiving water / location of discharge, if applicable:

______________________________________________________

D.3 - Factors that may Limit Environmental Exposure[6]

(see section 6.6.4.3 of the Guidelines)

Confidential? Y or N

Describe conditions during the life cycle of the substance that may limit environmental exposure:

______________________________________________________

______________________________________________________

______________________________________________________

D.4 - Releases of the Substance to the Aquatic Environment13

(see section 6.6.4.4 of the Guidelines)

Confidential? Y or N

Whether the substance is anticipated to be released to the aquatic environment in a quantity less than or equal to 3 kg per day, per site, the data substantiating the quantity released is required:

______________________________________________________

Total amount (kg/day) of releases or anticipated release directly to surface water:

______________________________________________________

Amount (kg/year) of discharges, if any, from on-site treatment and data substantiating the quantity of such releases:

______________________________________________________

Name of receiving water / location of discharge:

______________________________________________________

Description of any on-site treatment system(s), including percentage of notified substance removed, if known:

______________________________________________________

E - Transportation, Storage and Disposal Information Requirements

(see section 6.6.5 of the Guidelines)

E.1 - Transport and Storage Containers[12]

(see section 6.6.5.1 of the Guidelines)

Confidential? Y or N

Description of the expected modes for its transportation and storage:

______________________________________________________

UN Number, if known:

______________________________________________________

Description of the size and type of container(s) used for transportation and storage of the notified substance and/or product containing the notified substance:

______________________________________________________

______________________________________________________

Amount (kg/year) of substance shipped in each type of container, if known:

______________________________________________________

E.2 - Anticipated Disposal of the Notified Substance

(see section 6.6.5.2 of the Guidelines)

Confidential? Y or N

Description of the methods recommended for its destruction or disposal for industrial, commercial and consumer applications:

______________________________________________________

______________________________________________________

Total amount (kg/year) of the substance disposed of by each method, if known:

______________________________________________________

Describe types and expected amounts (kg/year) of wastes from the substance for each type of waste, if known:

______________________________________________________

______________________________________________________

Treatment and disposal method of containers, including those off-site, if known:

______________________________________________________

______________________________________________________

Provincial waste classification(s), if known:

______________________________________________________

Site(s) of disposal:

______________________________________________________

Appendix II - New Substances Fee Payment Form

This form is to be used for fulfilling the information requirements prescribed in the New Substances Fees Regulations of the Canadian Environmental Protection Act, 1999.

This form must be submitted to:

Mailing Address:
Executive Director, Program Development and Engagement Division
Department of the Environment
Ottawa ON, K1A 0H3

Courier Deliveries:
Executive Director, Program Development and Engagement Division
Department of the Environment
8th Floor, Fontaine Building
Gatineau QC, J8Y 3Y5

Departmental Use Only

Mail Log No.:

_________________________

NSN Reference No.:

_________________________

Date Received:

_________________________

Amount Paid:

_________________________

Reference No.:
_________________________

Please refer to Appendix 3 of the Guidelines for instructions on completing this form. A separate Fee Form must be submitted for each NSN package, except for consolidated notifications.

Assessment Fees (Schedule 1 of Fees)

Please circle the appropriate fee and report in box A below.

Company’s Annual Sales in Canada (millions) in Canadian dollars
NSNR Schedule less than or equal to 13 greater than 13 - less than or equal to 26 greater than 26 - less than or equal to 40 greater than 40
Schedule 1 (except R&D) $500 $1,000 $1,500 $2,000
Schedule 3 (except R&D) $500 $1,000 $1,500 $2,000
Schedule 4 $50 $100 $150 $200
Schedule 5 $500 $1,000 $1,500 $2,000
Schedule 6 $875 $1,750 $2,625 $3,500
Schedule 9 $125 $250 $375 $500
Schedule 10 $875 $1,750 $2,625 $3,500
Schedule 11 $875 $1,750 $2,625 $3,500

Assessment Fees (Schedule 2 of Fees)

Please circle the appropriate fee and report in box A below.

Company’s Annual Sales in Canada (millions) in Canadian dollars
NSNR Schedule less than or equal to 13 greater than 13 - less than or equal to 26 greater than 26 - less than or equal to 40 greater than 40
Schedule 5 finala $750 $1,500 $2,250 $3,000
Schedule 9 finalb $375 $750 $1,125 $1,500

Box A

Fee required for any schedule indicated above: _________________

Less any amount paid for the assessment of that substance as referenced below (Box B and Box C):

Box B

Schedule: _________________

NSN No.: _________________

Assessment Fee Paid: _________________

Box C

Schedule: _________________

NSN No.: _________________

Assessment Fee Paid: _________________

Box D

Subtotal D: _________________
(Box A - Box B - Box C, enter 0 if negative)

Assessment Fees for Matched Notifications or Consolidated Notifications

Please check appropriate box and enter appropriate information. Report in Subtotal E.

Assessment Fees
Type of Notification Fee (CDN$)
Matcheda with NSN No. _________________  $200
Consolidatedb (please indicate number of notifications, up to 5)
Please reference master notification below:
Schedule: _________________
Trade Name: _________________
____ × 250

Box E

Subtotal E: _________________

Fees for Other Services (Schedule 3 of Fees)

Please circle the appropriate fee and report in Subtotal F.

Company’s Annual Sales in Canada (millions) in Canadian dollars
Services less than or equal to 13 greater than 13 - less than or equal to 26 greater than 26 - less than or equal to 40 greater than 40
Confidential search of DSLaand NDSL[a] $62.50 $125 $187.50 $250
Masked name applicationb $150 $300 $450 $600
Application under Four Corners Arrangement $500 $1,000 $1,500 $2,000
Subtotal F  

Box F

Subtotal F: _________________

Summary Cost14

Subtotal D (Box D): _________________

Subtotal E (Box E): _________________

Subtotal F (Box F): _________________

Total Fees Payable (Box D + Box E + Box F):_________________

Credit Card Authorization Form

This form is protected when completed

I authorize payment of the New Substances fee to the Receiver General for Canada in the amount of:

C$ _____________

Please indicate your method of payment:

Visa
MasterCard
American Express

Card No.: ____________________________________________

Expiry Date: _________________
(MM/YYYY)

Security code: _________________
(Please enter your 3 or 4 digit Card ID Number found on the back of the card)

Cardholder name: ____________________________________________
(please print)

Company Name: ____________________________________________
(as found in Box A.1 of the Notification Form or Service Requester)

Telephone Number: (______) - ______________

Signature of the cardholder: ____________________________________________

Departmental Use Only

Mail Log No.:

_________________________

NSN Reference No.:

_________________________

Date Received:

_________________________

Amount debited:

_________________________

Authorization No.:

_________________________

Deposit Receipt No.:
_________________________

Disclaimer

Although care has been taken to ensure that the information accurately reflects the requirements prescribed, you are advised that should any inconsistencies be found, the legal documents, printed in the Canada Gazette, will prevail.
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