Mandatory annual tetrachloroethylene reporting form for dry cleaners

Annual Report for Dry Cleaners

[See Paragraph 14(b) and Schedule 4 of the Tetrachloroethylene (Use in Dry Cleaning and Reporting Requirements) Regulations]

Please note the following instructions:

• Fill in this form completely and legibly
• This annual report must be submitted no later than April 30 of the calendar year following the year in which the activities took place (such as April 30, 2024 for activities from January 1 to December 31, 2023)
• Submit the completed and signed annual report by email or mail to the Environment and Climate Change Canada office identified at the end of this form
• Complete a separate annual report for each dry-cleaning facility that you own or operate

A completed example of the report can be found here:

• Example Annual report for dry cleaners

Step 1: Identification of reporting year

January to December (year): ______________ 

Step 2: Identification of the dry-cleaning facility

Change of ownership? Yes or No
Note:  If the facility has changed ownership during the reporting year, list all owners or operators in Step 7, below. Each owner or operator must submit a report for their own activities. If the facility has closed, provide details in Step 7, below.

Information of the owner and operator of a dry-cleaning machine
Name of owner or operator:
Legal name of company (optional):
Business or trade name of company:
Civic (street) address of principal place of business:
Postal address of principal place of business (if different from civic (street) address):
Telephone number:
Ext:
Fax number (if any):
Email address (if any)*:

*Reporting reminders and form will be sent to this email address.

Information of the person authorized to act on behalf of the owner or operator
(to fill out if you are not the owner of the facility)
Name:
Title:
Name of company:
Civic (street) address of principal place of business:
Postal address of principal place of business (if different from civic (street) address):
Telephone number:
Extension:
Fax number (if any):
Email address (if any)*:

*Reporting reminders and form will be sent to this address.

Step 3: Purchase of tetrachloroethylene (PERC)   

Note: If you have made more than 5 purchases during the reporting year, add copies of this page.

One litre of tetrachloroethylene weighs 1.62 kilograms (kg). [1L = 1.62 kg]

Total number of tetrachloroethylene (PERC) purchases:

Purchase #1:
Date of purchase (yyyy-mm-dd):
Quantity of tetrachloroethylene purchased (kilograms):

Purchase #2:
Date of purchase (yyyy-mm-dd):
Quantity of tetrachloroethylene purchased (kilograms):

Purchase #3:
Date of purchase (yyyy-mm-dd):
Quantity of tetrachloroethylene purchased (kilograms):

Purchase #4:
Date of purchase (yyyy-mm-dd):
Quantity of tetrachloroethylene purchased (kilograms):

Purchase #5:
Date of purchase (yyyy-mm-dd):
Quantity of tetrachloroethylene purchased (kilograms):

Company name of supplier (optional):

Step 4: Identification of dry-cleaning machine(s)

Note:

• If you have more than 3 dry-cleaning machines, add copies of this page
• refer to paragraph 8(1)(b) of the Regulations for details regarding waste water treatment systems

Dry-cleaning machine #1:
Machine make:
Machine model:
Machine serial number:
Machine cleaning capacity (indicate amount in kg or lb):
Is the machine equipped with an integral refrigerated condenser? Yes or No
Was the machine installed or in use before August 1, 2003? Yes or No
Is waste water from the machine treated by an on-site waste water treatment system? Yes or No

Dry-cleaning machine #2 (if applicable):
Machine make:
Machine model:
Machine serial number:
Machine cleaning capacity (indicate amount in kg or lb):
Is the machine equipped with an integral refrigerated condenser? Yes or No
Was the machine installed or in use before August 1, 2003? Yes or No
Is waste water from the machine treated by an on-site waste water treatment system? Yes or No

Dry-cleaning machine #3 (if applicable):
Machine make:
Machine model:
Machine serial number:
Machine cleaning capacity (indicate amount in kg or lb):
Is the machine equipped with an integral refrigerated condenser? Yes or No
Was the machine installed or in use before August 1, 2003? Yes or No
Is waste water from the machine treated by an on-site waste water treatment system? Yes or No

Step 5: Waste management

Note: Add copies of this page if:

• you have more than 5 transports (Part A)
• you have used a different transport company (Part B) for each transport
• you have used a different waste management facility (Part C) for each transport

Part A: information of the transport of wastewater and residue**

Describe each transport during the year for which your waste was transported to a waste management facility (Please don't send any invoice).

Transport #1:
Date (yyyy-mm-dd):
Type and quantity of waste transported (fill out at least 1 of the 3 categories below):

• Wastewater only (indicate amount in kg or L):
• Residue** only (indicate amount in kg or L):
• Mix of wastewater and residue* (indicate amount in kg or L):

Transport #2:
Date (yyyy-mm-dd):
Type and quantity of waste transported (fill out at least 1 of the 3 categories below):

• Wastewater only (indicate amount in kg or L):
• Residue** only (indicate amount in kg or L):
• Mix of wastewater and residue* (indicate amount in kg or L):

Transport #3:
Date (yyyy-mm-dd):
Type and quantity of waste transported (fill out at least 1 of the 3 categories below):

• Wastewater only (indicate amount in kg or L):
• Residue** only (indicate amount in kg or L):
• Mix of wastewater and residue* (indicate amount in kg or L):

Transport #4:
Date (yyyy-mm-dd):
Type and quantity of waste transported (fill out at least 1 of the 3 categories below):

• Wastewater only (indicate amount in kg or L):
• Residue** only (indicate amount in kg or L):
• Mix of wastewater and residue* (indicate amount in kg or L):

Transport #5:
Date (yyyy-mm-dd):
Type and quantity of waste transported (fill out at least 1 of the 3 categories below):

• Wastewater only (indicate amount in kg or L):
• Residue** only (indicate amount in kg or L):
• Mix of wastewater and residue* (indicate amount in kg or L):

**Residue means any solid, liquid or sludge waste containing tetrachloroethylene. Examples may include lint, muck/sludge, solvent filters (cartridge and spin disk), still bottoms, and so on. Report these in kg or L. 

Part B: information of the company that made the transport

Name of company that made the transport:
Civic (street) address of principal place of business of company that made the transport:
Postal address of principal place of business (if different from civic address):
Telephone number:

Part C: information of the waste management facility (if different from Part B)

Same as the company named in Part B? yes or no

If waste management facility is different from the company named in Part B, provide:

Name of waste management facility:
Civic (street) address of principal place of business of waste management facility:
Postal address of principal place of business (if different from civic address):
Telephone number:

Step 6: Request for confidentiality

Indicate if you are requesting confidentiality under Section 313 of the Canadian Environmental Protection Act, 1999 (CEPA 1999).

Pursuant to section 313 of the Canadian Environmental Protection Act, 1999 (the Act), any person who provides information in this form may submit, with the information, a written request that it be treated as confidential. A request for confidentiality may be submitted for all or part of the information provided. When requesting confidentiality, specify the parts (e.g. sections or tables) of the information that you request be treated as confidential. A request should only be made for information that is truly confidential.

When submitting a request for confidentiality, the following criteria should be considered:

• the information is confidential to your company and has consistently been treated as such by your company,
• your company has taken, and intends to continue to take, measures that are reasonable in the circumstances to maintain the confidentiality of the information,
• the information is not, and has not been, reasonably obtainable by third persons by use of legitimate means, except with the consent of your company,
• the information is not available to the public,
• disclosure of the information may reasonably be expected to cause substantial harm to the competitive position of your company, or
• disclosure of the information may reasonably be expected to result in a material financial loss to your company or a material financial gain to your company’s competitors.

Upon receipt of a request for confidentiality under section 313 of the Act, in relation to information submitted, the Minister of the Environment shall not disclose that information, except in accordance with the law.

• I do not request that the information I am submitting be treated as confidential, and I consent to it being released without restriction; or
• Pursuant to section 313 of the CEPA 1999, I request that the following parts of the information that I am submitting be treated as confidential.
  •  Specify the parts [such as sections or tables] of the information that you request be treated as confidential (mandatory).
  •  Include the reason for your request (mandatory).

 

 

 

Step 7: Additional comments or information

 

• The facility ceased operations during this reporting year. Closing date: (yyyy-mm-dd)
• The facility changed ownership during this reporting year. Effective date: (yyy-mm-dd)

Step 8: Signature

• You must sign and date this section
• It is an offence under the Canadian Environmental Protection Act, 1999 and the Regulations to submit an incomplete form.

I, __________________________, (print your name), am the owner or operator of a dry-cleaning facility and I am an authorized representative of _____________________________________ (print the name of the dry-cleaning facility).

OR

I, __________________________, (print your name), am an authorized representative assigned by the owner or operator of a dry-cleaning facility  _____________________________________ (print the name of the dry-cleaning facility). 

AND

I declare that the information provided in this annual report is true, accurate and complete.

I acknowledge that if I electronically-signed this annual report, I am bound by the terms of the annual report and that it is enforceable with the same legal obligations as if I had signed a paper version of this annual report by handwritten signature and that this annual report electronically signed is deemed to be the original annual report.

I acknowledge that I must keep a copy of this annual report at the principal place of business in Canada for a period of five years after the end of the year in which the report is made.

 

____________________________________________________
SIGNATURE of owner or operator, or the authorized representative to act on behalf of the owner or operator.

Date (yyyy/mm/dd): _______________ 

Total number of pages in this annual report: _______________