ANNUAL REPORT FOR RECYCLERS OF TETRACHLOROETHYLENE IN CANADA
[see Paragraph 12(b) and Schedule 2 of Tetrachloroethylene (Use in Dry Cleaning and Reporting Requirements) Regulations]	

NOTE:  In completing the annual report to Environment Canada, recyclers can either use:
•	this form; or 
•	another form/format of their own choosing, provided that the submitted report contains all the required information outlined in Paragraph 12(b), Section 15 and Schedule 2 of the regulations.

Information Respecting the Recycler	
Name of Recycler:	
Name of Company:	
Civic (street) Address of Principal Place of Business:

	
Postal Address of Principal Place of Business:                                   Same as Civic (street) Address

Phone Number:  (         )	Fax Number (if any): (         )	
E-mail Address (if any):	
Information on Person Authorized to Act on Behalf of the Recycler (if applicable)	
Name:	
Title:	
Name of Company:	
Civic (street) Address of Principal Place of Business:

	
Postal Address of Principal Place of Business:                                   Same as Civic (street) Address

Phone Number:  (         )	Fax Number (if any): (         )	
E-mail Address (if any):	
Information on Quantity of Tetrachloroethylene Recycled	
Calendar Year:	
Total Quantity Recycled:	kg	
•	Total Quantity Recycled for Re-use in Dry cleaning:	kg	
•	Total Quantity Recycled for Re-use in Degreasing:	kg	
•	Total Quantity Recycled for Other Uses:
•	please specify the other uses:	kg	

ANNUAL REPORT FOR RECYCLERS OF TETRACHLOROETHYLENE IN CANADA
[see Paragraph 12(b) and Schedule 2 of Tetrachloroethylene (Use in Dry Cleaning and Reporting Requirements) Regulations]	

Request for Confidentiality	
INDICATE IF YOU ARE REQUESTING CONFIDENTIALITY UNDER SECTION 313 OF THE CANADIAN ENVIRONMENTAL PROTECTION ACT, 1999? 
 NO
 YES   (NOTE: A reason for this request is required and must be submitted along with this report – please provide the reasons below or on an additional page):

	

	

I, ___________________________________________________________________________________________, 
(write down name of recycler, or the person who is authorized to act on behalf of the recycler or corporation)

declare that the information provided in this annual report is correct.

________________________________________________	___________________________________________
Date and place	Total Number of Pages in this annual report

____________________________________________________________________________________________________
Signature of recycler, or of person who is authorized to act on behalf of the recycler or corporation

This annual report must be submitted by mail
no later than April 30, 2013  for the 2012 Reporting year.

Submit the completed and signed annual report to the regional
Environment Canada office serving your area.

Environment Canada office addresses and contact information can be found at:
http://www.ec.gc.ca/regs-tetra/