Revised pollution prevention plans for inorganic chloramines and chlorinated wastewater effluents: schedule 5

Schedule 5: Declaration That a Pollution Prevention Plan Has Been Implemented - Inorganic Chloramines and Chlorinated Wastewater Effluents (Subsection 58(2) of CEPA 1999)

NOTE: Please contact the National Office of Pollution Prevention for more information about electronic reporting or the filing of paper forms.

Notice Reference Code:P2CLMWWE

• 1.0 Information on the Person or Class of Persons Subject to the Notice
• 2.0 No data are required for part 2.0 of this Declaration
• 3.0 Substance and Activity
• 4.0 Baseline Information after Implementation of the Pollution Prevention (P2) Plan
  • 4.1 - 4.4 No information required for Parts 4.1 to 4.4 of this Declaration
  • 4.5 Additional Baseline Information
• 5.0 Action(s) Taken and Results Achieved
  • 5.1 Action(s) Taken
  • 5.2 No information required for Part 5.2 of this Declaration
  • 5.3 Detailed Results Achieved Information
• 6.0 Monitoring and Reporting
• 7.0 Risk Management Objective
• 8.0 No information is required for Part 8.0 of this Declaration
• 9.0 Certification

Please refer to the instruction booklet "Instructions for Completing the Schedules of the Canada Gazette Notice Requiring the Preparation and Implementation of Pollution Prevention Plans for Inorganic Chloramines and Chlorinated Wastewater Effluents" for guidance on how to complete this Request. Electronic copies of the Notice, and the instructions for completing the declarations (Schedules 1 to 5), are available from the Pollution Prevention website or can be requested by telephone at 819-994-0186, by fax at 819-953-7970, or by email; CEPAP2Plans@ec.gc.ca.

Is this an amendment to a Declaration previously submitted?  Yes  ▢  No ▢

If yes, complete Parts 1.0 and 9.0 and any other Parts of this Declaration where previously reported information has become false or misleading. Previously reported information that is unchanged need not be resubmitted.

1.0 Information on the Person or Class of Persons Subject to the Notice

Name of the Person or Class of Persons Subject to the Notice: ____________
Facility Name: ____________
Street Address of Facility: ____________
City: ____________
Province/Territory: ____________
Postal Code: ____________
Telephone number: (with area code) ____________
e-mail (if available): ____________

If different from Street Address
Mailing Address of Facility: ____________
City: ____________
Province/Territory: ____________
Postal Code: ____________

National Pollutant Release Inventory ID (if no ID, leave blank): ____________
6-digit North American Industry Classification System (NAICS) Code: 221320

Facility Technical Contact: ____________
e-mail (if available): ____________
Telephone Number: (with area code) ____________
Fax Number (if available): (with area code) ____________

2.0 No data are required for part 2.0 of this Declaration

3.0 Substance and Activity

Substance and Activity for which information is required.

Inorganic Chloramines and Chlorinated Wastewater Effluents: Persons identified in section 2 of the Notice who are required to prepare and implement a pollution prevention plan for inorganic chloramines and chlorinated wastewater effluents for the use of chlorine or chlorine compounds in wastewater systems and the release of chlorinated effluent to surface water.

4.0 Baseline Information after Implementation of the Pollution Prevention (P2) Plan

This Declaration requires reporting of data for the year of implementation (January 1 to December 31) of the pollution prevention plan, but no later than for the year 2009 (as specified in the Notice or any other year specified to a person who has been granted an extension of time to implement a plan).

Indicate the year of implementation for which the person(s) is (are) reporting: _______ (This will be the Reporting Year throughout this Declaration).

4.1 - 4.4 No information required for Parts 4.1 to 4.4 of this Declaration

4.5 Additional Baseline Information

4.5.1 Wastewater System Information

Describe the changes to your wastewater system since 2004 or 2005, compared to the information provided in Schedule 1 - Declaration that a pollution prevention plan has been prepared and is being implemented.

___________________________________________________________

4.5.2 Releases to Surface Water

4.5.2.1 Inorganic Chloramines and Chlorinated Wastewater Effluents

Report in the table below the average flow of wastewater effluent and the maximum Total Residual Chlorine (TRC) concentrations. The average monthly flow should be determined on the basis of daily flow measurements. The maximum total residual chlorine concentration should be determined on the basis of representative sampling.

5.0 Action(s) Taken and Results Achieved

5.1 Action(s) Taken

The following section (Parts 5.1.1. through 5.1.6) must be completed separately for each action taken in the P2 plan, i.e., this section will be completed as many times as there are actions taken to report.

In Part 5.1.1, describe for the activity identified in Part 3.0 of this Declaration, the action taken in implementing the Pollution Prevention Plan. In Parts 5.1.2 and 5.1.3, identify whether the action represents pollution prevention method(s) or other environmental protection method(s), by selecting from the list of options provided below. In Part 5.1.4, report, where possible, the corresponding change to the maximum concentration of total residual chlorine measured in the effluent released to surface water achieved from implementation of that action, in mg/L. Refer to the instructions for specific information on how to report. Indicate a decrease with a negative sign ("-") and an increase with a positive sign ("+") in front of the reported change. Note that estimating a quantitative change for some actions taken, such as training, may not be possible. Finally, in Part 5.1.6, identify the completion date for each action taken.

5.1.1 Action Taken:_________________________________________

5.1.2 Type of Pollution Prevention Method(s):

▢ Equipment or process modifications
▢ On-site reuse, recycling or recovery
▢ Spill and leak prevention
▢ Good operating practices or training
▢ Other: _________________________________________

 5.1.3 Other Type of Environmental Protection Method(s):

▢ Energy recovery
▢ Pollution control
▢ Off-site recycling
▢ Disposal
▢ Waste treatment
▢ Other: _________________________________________

5.1.4 Results of actions taken in 5.1.1

__________________________________________________

5.1.5 No information is required for Part 5.1.5 of this Declaration.

5.1.6 Completion Date (year/month/day):

__________________________________________________

This ends the section (Parts 5.1.1. through 5.1.6) that must be completed separately for each action taken in the P2 plan.

5.2 No information required for Part 5.2 of this Declaration

5.3 Detailed Results Achieved Information

Total Results Achieved for Inorganic Chloramines and Chlorinated Wastewater Effluents

The table below summarizes, for the activity identified in Part 3.0 of this Declaration, the achieved change to the maximum concentration of total residual chlorine (TRC) in the effluent released to surface water, in mg/L, and as a percentage relative to the preparation year.

Report the change achieved from all actions taken as a result of implementing the pollution prevention plan.

* Indicate a decrease with a negative sign ("-") and an increase with a positive sign ("+") in front of the reported change.

6.0 Monitoring and Reporting

For the activity identified in Part 3.0 of this Declaration, describe the monitoring and reporting used to track progress in implementing the Pollution Prevention Plan.

__________________________________________________

7.0 Risk Management Objective

For the activity identified in Part 3.0 of this Declaration, describe how the Pollution Prevention Plan outlined in this Declaration met the risk management objective identified in subsection 4(3) of the Notice. If this plan did not meet the risk management objective, explain why.

__________________________________________________

8.0 No information is required for Part 8.0 of this Declaration

9.0 Certification

I hereby certify that the information provided in this Request is true, accurate and complete.

___________________________________________________________
Signature of the Person(s) subject to the Notice or Duly Authorized Representative

___________________________________________________________
Date

Name:
___________________________________________________________
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Title/Position:
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