Note: Do not fill out this form. This form presents an example of the range and type of information that may be required and will be modified on a Notice-by-Notice basis.

Schedule 1: Declaration That a Pollution Prevention Plan Has Been Prepared and Is Being Implemented - [Substance name] (Subsection 58(1) of CEPA 1999)

Notice Reference Code: _____________

Please refer to the instruction booklet “Instructions for Completing the Schedules to the Canada Gazette Notice Requiring the Preparation and Implementation of Pollution Prevention Plans in Respect of [substance(s) name as per title of Notice]” for guidance on how to complete this Declaration.

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): _________________
Email (if available): __________________________________________

If different from Street Address
Mailing Address of Facility: ______________________________________
City: ____________________ Province/Territory: _________________
Postal Code: ______________

National Pollutant Release Inventory ID (if available): _____________________
6-digit North American Industry Classification System (NAICS) Code: _______________

Facility Technical Contact: ____________________________________
Email: _______________________________________
Telephone Number with Area Code: _____________________
Fax Number - with Area Code (if available): _____________________

2.0 Use of Plans Prepared or Implemented for Another Purpose

Is the pollution prevention plan used to fulfill the obligations of this Notice:

• a pollution prevention plan that was previously prepared on a voluntary basis? __ Yes  __ No
• a pollution prevention plan that was previously prepared for another government or under another Act of Parliament? __ Yes __ No

If yes, identify the other government requirement(s) or Act(s) of Parliament. _________________________________________________

The following section (Parts 3.0 through 7.0) must be completed separately for each combination of Substance, Activity, and/or Class of Person(s) selected in Part 3 below [if applicable].

3.0 Substance, Activity, and/or Class of Person(s)

Substance, Activity, and/or Class of Person(s) for which information is required [(choose one)]:

__ [Substance X and Activity X]
__ [Class of Person(s)]

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

Notes:

(a) The data collected in Parts [4.X] of this Declaration are consistent with the reporting requirements of the National Pollutant Release Inventory (NPRI) where possible.

(b) Use the following Basis of Estimate Codes where indicated, listed in declining order of expected accuracy, to describe how each quantity reported in this Part of the Declaration was determined:

• M1 - Continuous Emission Monitoring System
• M2 - Predictive Emission Monitoring
• M3 - Source Testing
• C - Mass balance
• E1 - Site-specific and Published Emission Factors
• E2 - Published Emission Factors
• O - Engineering estimates

(c) This Declaration requires reporting of data from the Preparation Year⁹ [e.g. 2007] (January 1 to December 31). 

If the person(s) subject to the Notice has (have) been granted a time extension to prepare a plan that requires reporting for a year other than [2007], all references to [2007] in this Declaration are considered to represent the new Preparation Year for which the person(s) is (are) required to report.

If applicable, indicate the new Preparation Year for which you are reporting: _____________

4.1 Nature of Activity

For the activity identified in Part 3.0 of this Declaration, indicate whether the Substance was manufactured, processed, distributed or otherwise used, and the nature of such activity at the facility for the Preparation Year. More than one nature of activity may be identified.

Note: Sections 4.2 – 4.4 may ask for release information or transfer information or both, depending on Notice.

4.2 On-Site Uses

For the activity identified in Part 3.0, did this facility use the Substance on-site in the Preparation Year? __ Yes  __ No

If yes, for the activity identified in Part 3.0 of this Declaration, report below the total quantity of all on-site uses of the Substance, in [kilograms (kg)] for that year with the basis of estimate code and indicate how the Substance is used (see Part 4.0, Note b).

If no, proceed to Part 4.3 of this Declaration.

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4.3 On-Site Releases

For the activity identified in Part 3.0 of this Declaration, did this facility release the Substance on-site in the Preparation Year? __ Yes   __ No

If yes, report below the quantity of all on-site releases of the Substance in [kilograms (kg)] for that year in the appropriate field.

If no, proceed to Part 4.4 of this Declaration.

4.3.1 Releases to Air

For the activity identified in Part 3.0 of this Declaration, report the quantity of all releases of the Substance to air with the basis of estimate code (see Part 4.0, Note b), indicating the type(s) of release(s). Include routine, accidental, and non-routine releases.

4.3.2 Underground Injection

For the activity identified in Part 3.0 of this Declaration, report the total quantity of the Substance injected underground on-site with the basis of estimate code (see Part 4.0, Note b).

4.3.3 Releases to Surface Waters

For the activity identified in Part 3.0 of this Declaration, report the quantity of all releases of the Substance to surface waters with the basis of estimate code (see Part 4.0, Note b), indicating the type(s) of release(s).

4.3.4 Releases to Land

For the activity identified in Part 3.0 of this Declaration, report the quantity of all releases of the Substance to land within the boundaries of the facility with the basis of estimate code (see Part 4.0, Note b), indicating the type(s) of release(s).

4.3.5 Total Releases

For the activity identified in Part 3.0 of this Declaration, report the total quantity, in [kg/year], of the Substance released on-site.

4.4 Off-Site Transfers

4.4.1 Product Distribution

For the activity identified in Part 3.0 of this Declaration, did this facility distribute the Substance off-site as a product or part of a product in the Preparation Year?
__ Yes __ No

If yes, report below the quantity of all off-site transfers of the Substance for distribution in [kg/year], as a product or part of a product with the basis of estimate code (see Part 4.0, Note b), indicating the type(s) of transfer(s). Indicate the expected use of the Substance and the expected disposal method, if known.

If no, proceed to Part 4.4.2 of this Declaration.

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4.4.2  Off-Site Transfers for Disposal

For the activity identified in Part 3.0 of this Declaration, did this facility transfer the Substance off-site for disposal in the Preparation Year? __ Yes   __ No

If yes, for the activity identified in Part 3.0 of this Declaration, report below the quantity of all off-site transfers of the Substance for disposal in [kg] with the basis of estimate code (see Part 4.0, Note b), indicating the type(s) of transfer(s). Report only the net mass of the Substance that was sent off-site, not the total mass of the mixture containing the Substance. Report transfers to the first off-site location only and not any subsequent transfers by the waste disposal company.

If no, proceed to Part 4.4.3 of this Declaration.

4.4.3 Off-Site Transfers for Recycling

For the activity identified in Part 3.0 of this Declaration, did this facility transfer the Substance off-site for recycling in the Preparation Year? __ Yes   __ No

If yes, report below the quantity of all off-site transfers of the Substance for recycling, in [kg] for that year in the appropriate field.

If no, proceed to Part 4.4.4 of this Declaration.

For the activity identified in Part 3.0 of this Declaration, report the quantity of all off-site transfers of the Substance for recycling with the basis of estimate code (see Part 4.0, Note b). Report only the net mass of the Substance that was sent off-site, not the total mass of the mixture containing the Substance. Report transfers to the first off-site location only and not any subsequent transfers by the recycling facility.

4.4.4 Total Off-Site Transfers

For the activity identified in Part 3.0 of this Declaration, report the total quantity, in [kg/year], of total off-site transfers of the Substance.

4.5 Additional Baseline Information

Note: Part 4.5 is a module that may be tailored to each Notice. It is used to collect any necessary information that is not already collected in Part 4.

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5.0 Anticipated Actions and Results

5.1 Anticipated Action(s)

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

In Part 5.1.1, describe for the activity identified in Part 3.0 of this Declaration, the anticipated action to be taken in implementing the Pollution Prevention Plan.

5.1.1 Anticipated Action: _____________________________________________

In Parts 5.1.2 and 5.1.3, identify whether the anticipated action represents pollution prevention method(s) or other environmental protection method(s), by selecting from the list of options provided below.

5.1.2 Type of Pollution Prevention Method(s):

For a detailed description of pollution prevention methods, please refer to the Pollution Prevention Planning Handbook.

__ Material or feedstock substitution
__ Product design or reformulation
__ Equipment or process modifications
__ Spill and leak prevention
__ On-site reuse recycling or recovery
__ Inventory management or purchasing techniques
__ Good operating practices or training
__ Other: _______________________________

5.1.3 Other Type of Environmental Protection Method(s):

__ Energy recovery
__ Off-site recycling
__ Incineration with energy recovery
__ Waste treatment
__ Pollution control
__ Disposal
__ Other: ______________________________

In Part 5.1.4, report, where possible, the corresponding change to annual uses, releases and/or transfers of the Substance anticipated to be achieved from implementation of that action in [kg]. Indicate a decrease with a negative sign (“-”) and an increase with a positive sign (“+”) in front of the reported quantity. Note that predicting a quantitative change for some anticipated actions, such as training, may not be possible.

5.1.4 Anticipated Change(s):
_______________________________________________

In Part 5.1.5, relate these changes to a specific element(s) of the baseline information described in Part 4 of this Declaration using the appropriate alphabetical label. Refer to the Instruction Booklet for a listing of alphabetical labels. 

5.1.5 Baseline Element(s) Affected:
_______________________________________________

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Finally, in Part 5.1.6, identify the planned completion date for the anticipated action.

5.1.6 Planned Completion Date (year/month/day): __________

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

5.2 Total Anticipated Results

The table below summarizes, for the activity identified in Part 3.0, the total anticipated change to annual  [uses, releases and/or transfers] of the Substance in [kg] [and as a percentage] relative to the Preparation Year.

Relative to the Preparation Year, report the total changes anticipated to be achieved from implementing only the anticipated actions described in Part 5.1 of this Declaration. 

Important: Indicate a decrease with a negative sign (“-”) and an increase with a positive sign (“+”) in front of the reported quantity and percent change below.

5.3 Detailed Anticipated Results Information

Note: Part 5.3 is a module that may be tailored to each Notice. It is used to collect any necessary information that is not already collected in part 5.

6.0 Monitoring and Reporting

Describe anticipated monitoring and reporting that will be used to track progress in implementing the Pollution Prevention Plan.
________________________________________________________________
________________________________________________________________
________________________________________________________________

7.0 Risk Management Objective

Describe how the Pollution Prevention Plan outlined in this Declaration will meet the risk management objective identified in the Notice. If this plan will not meet the risk management objective, explain why.
________________________________________________________________
________________________________________________________________
________________________________________________________________

This ends the section (Parts 3.0 through 7.0 of this Declaration) to be completed separately for each combination of Substance, Activity, and/or Class or Person(s) specified in Part 3.0 above.

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8.0 Factors to Consider

Describe what was done by the person or class of persons subject to the Notice to take into account the “factors to be considered” identified in paragraph [X] of the Notice.

8.1 Additional Information

Note: Part 8.1 is a module that may be tailored to each Notice. It is used to collect any necessary information that is not already collected in this Declaration.

9.0 Certification

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

____________________________________________
Signature of the Person(s) Subject to the Notice
or Duly Authorized Representative

________________________
Date

Name: ______________________________ (Please Print)

Title/Position: _________________________ (Please Print)

⁹ Preparation Year typically refers to the year in which the P2 plan is prepared.

Note: Text in brackets (e.g. [text]) will vary on a Notice-by-Notice basis.