Declaration of Non-Engagement

Notice with respect to certain high priority petroleum substances on the Domestic Substances List (DSL)

(PDF Version - 34 KB)

Persons, including companies, that do not meet the requirements of the Notice with respect to certain high priority petroleum substances on the Domestic Substances List (DSL)[*] are encouraged to complete this form and return the signed document to the address indicated at the bottom of this page.

Identification

 Please replace, add or update the identification information

 Please remove us from the database because we are no longer in business

Name of the person (e.g. company) :
_____________________________________________________________________

Canadian head office street address (and mailing address, if different from the street address):
_____________________________________________________________________

Federal Business Number[1]:
_____________________________________________________________________

Contact name for the Canadian Environmental Protection Act, 1999 (CEPA 1999) section 71 notices:
 Mr.  Ms.  Dr.
_____________________________________________________________________

Title of contact:
_____________________________________________________________________

Contact’s street and mailing addresses (if different from above):
_____________________________________________________________________

Telephone number:
( _____ ) _____ - __________

Fax number:
( _____ ) _____ - __________

Email address:
_____________________________________________________________________

Non-Engagement Declaration

 This person (e.g. company) was not engaged in the activities described in the Schedule 2 to the Notice, published in the Canada Gazette, Part I, on December 17, 2011.

_____________________________________________________________________
Name (print)

_____________________________________________________________________
Title

_____________________________________________________________________
Signature

_____________________________________________________________________
Date of Signature

Please return this form to the attention of the Substances Management Coordinator, Chemicals Management Plan:

200 Sacré-Cœur Boulevard,
Gatineau, Quebec 
K1A 0H3
Telephone: (800) 567-1999 (Toll Free in Canada) or (819) 953-7156 (Outside of Canada)
Facsimile: (819) 953-7155
Chemical Substances Website

Footnotes

[*] Note: Requirements of the Notice are described in Schedule 2 to the Notice published in the Canada Gazette, Part I, on December 17, 2011.
[1] Federal business number is a nine-digit registration number issued by the Canada Revenue Agency (CRA) to Canadian businesses that register for one or more of the following: corporate income tax; importer/exporter account number; payroll (source) deductions (trust accounts); or goods and services tax. This number can be found on all forms issued to a business by the CRA. The first nine digits that appear on these forms is the Federal business number.