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:
- This form or
- Another form or format of their own choosing, provided that the submitted report contains all the required information outlined in Subsection 11(b), Section 15 and Schedule 3 of the Regulations.
- 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, 2025 for activities from January 1 to December 31, 2024).
- Submit the completed and signed annual report per email or mail to the Environment and Climate Change Canada office identified at the end of this form.
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:
- 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).
Signature and date
- 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 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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