Domestic Substances List Reporting Form printable pdf download

FORM NUMBER

DOMESTIC SUBSTANCES LIST REPORTING FORM

( DISPONIBLE EN FRANÇAIS)

DEPARTMENT USE ONLY

I. Certification Statement:

I hereby certify that to the best of my information, knowledge and belief: (1) the substance identified below was, between January 1, 1984 and December 31, 1986,

manufactured in or imported into Canada, by the person or corporation identified in Block II of this form, in a quantity of not less than 100 kg in any one calendar year,

or in Canadian commerce or used for commercial manufacturing purposes in Canada; and (2) the information for which confidentiality is claimed, meets the criteria for

determining confidentiality as outlined on the back of this form. It is understood that section 66 of the Canadian Environmental Protection Act, 1999 requires that the

Minister be “satisfied” that all substances specified on the Domestic Substances List meet the requirements set out in section 66 of the Act; therefore further

documentation may be requested to establish that a substance identified below meets those requirements.

Name and Title (Type or Print)

Signature

DATE

Foreign Supplier’s Name

Signature

DATE

II. Corporate Headquarters

III. Site of Manufacture (Manufacturer’s use only)

Corporation

Street

City

Province

Postal Code

City

Province

Postal Code

Telephone

Facsimile

E-mail

Telephone

Facsimile

E-mail

IV. Principal Technical Contact:

Address

Telephone

V. Substance Information (check)

Confidential Claims

Destination of Import (Importer’s Use Only)

Activity:

Qty

Use Code(s)

Use

North-West Territories

Quebec

(1986)*

(3 maximum)

Quantity

Yukon

Ontario

Manufacture

Activity

Newfoundland

Manitoba

Import

____

Site of manufacture

Prince-Edward Island

Saskatchewan

In Commerce

Corporation

Nova Scotia

Alberta

Substance Identity

New Brunswick

British Columbia

Substance identity is confidential

(1) Substantiation -

Number of sheets attached (Write the CAS / IUBMB Registry Number on all sheets)

____________________________________________________________

(2) Proposed Masked Name

CAS / IUBMB Registry Number

Specific Substance Name (Separate alternate names with a semi-colon):

Line

In the space below, provide structural information, molecular Formula and other supplemental information to aids in the specific identification of this substance.

____

____________________________________________________________________

Number of sheets attached

Molecular Formula

(Write the CAS / IUBMB Registry Number on each sheet)

* Nominators will be required to provide proof of eligibility of the substances. This will most often consist of records of sale, purchase, production/manufacture and

import (e.g. Canada Customs and Revenue Agency’s B3 forms or contracts with import-brokers). Where evidence is not provided or deemed inadequate, a substance

may be deleted from the DSL.

DO NOT WRITE BELOW THIS LINE

Environment Canada

Received

Signature:

Replacing Form No:

Batch Number

Transmitted:

Name:

Replacing Line No:

04-2619 (03/03)

DOE / CAP 300-03228