Annual report for sellers of tetrachloroethylene (PERC)

[See Subsection 11(b) and Schedule 3 of Tetrachloroethylene (Use in Dry Cleaning and Reporting Requirements) Regulations]

Note: to complete the annual report, importers can either use:

Identification of reporting year: January to December (year): _________

Information regarding the seller

Name of seller:

Name of company:

Civic (street) address of principal place of business:

Postal address of principal place of business (if different from civic (street) address):     

Phone number:

Ext:

Fax number (if any):

Email address (if any)*:

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

Information of the person authorized to act on behalf of the seller (if applicable)

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):     

Phone number:

Ext:

Fax number (if any):

Email address (if any)*:

*Reporting reminder and form will be sent to this email address

Information on quantity of tetrachloroethylene sold

Total quantity of virgin tetrachloroethylene sold to dry-cleaning facilities (kg):

Total quantity of recycled tetrachloroethylene sold to dry-cleaning facilities (kg):

Note:  If there is insufficient space below for you to report all sales of tetrachloroethylene during the calendar year, add copies to this page.

Date of sale: Name of company sold to: Civic (street) address: Postal address (if applicable): Name of the owner or operator: Quantity of  virgin tetrachloroethylene sold (kg): Quantity of recycled tetrachloroethylene sold (kg):
             
             
             
             
             
             
             
             
             

Request for confidentiality

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, tables) of the information to 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:

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.

 

 

 

Signature and date

I, __________________________, (print your name), am the seller and I am an authorized representative of _____________________________________ (print the name of the company).

OR

I, __________________________, (print your name), am an authorized representative assigned by   _____________________________________ (print the name of the company). 

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 the seller or the authorized representative to act on behalf of the seller

Date (yyyy/mm/dd): _______________ 

Total number of pages in this annual report: _______________

To submit your form

Once completed, send your annual report to produits-products@ec.gc.ca or mail your annual report to: 

          PERC Coordinator
          Chemical Productions and Products Division
          Environment and Climate Change Canada  
          351 Boulevard Saint‐Joseph, 9th floor
          Gatineau, QC K1A 0H3

Regional contacts information can be found at www.canada.ca/PERC‐contact‐information

Telephone: 1-800-668-6767 (EnviroInfo)

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