FORM NUMBER
DEPARTMENT USE ONLY /
DOMESTIC SUBSTANCES LIST REPORTING FORM
( DISPONIBLE EN FRANÇAIS)
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
YMD
||
Foreign Supplier’s Name / Signature / DATE
YMD
||
II. Corporate Headquarters
Corporation / III. Site of Manufacture (Manufacturer’s use only)
Corporation
Street / 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:
Manufacture
Import
In Commerce / Qty
(1986)*
____ kg / Use Code(s)
(3 maximum) / Use
Quantity
Activity
Site of manufacture
Corporation
Substance Identity / North-WestTerritories
Yukon
Newfoundland
Prince-Edward Island
Nova Scotia
New Brunswick / Quebec 
Ontario
Manitoba
Saskatchewan
Alberta 
British Columbia
If Substance identity is confidential
(1) Substantiation - Number of sheets attached (Write the CAS / IUBMB Registry Number on all sheets)
(2) Proposed Masked Name______
Line
1 / CAS / IUBMB Registry Number / Specific Substance Name (Separate alternate names with a semi-colon):
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
Batch Number / Received / Signature: / Replacing Form No:
Transmitted: / Name: / Replacing Line No:

04-2619 (03/03)DOE / CAP 300-03228

CERTIFICATION STATEMENT BY FOREIGN SUPPLIER

I hereby certify that, to the best of my information, knowledge and belief, all information which I have entered on this form, on behalf of the Canadian importer identified on the front of this form, is complete and accurate.

Amount (1986) Codes

Code / KG
A / Under / 100
B / 100 / - / 1 000
C / 1 000 / - / 10 000
D / 10 000 / - / 100 000
E / 100 000 / - / 1 000 000
F / 1 000 000 / - / 10 000 000
G / Over / 10 000 000
N / Nil / - / (Substance did not meet eligibility criteria in 1986, but did meet eligibility criteria in 1984 or 1985)

For additional information on reporting quantities, refer to the Amount section of the How To Report chapter in the Environment Canada guideline document, Reporting For The Domestic Substances List.

USE CODES

Information pertaining to the particular use(s) of reported substances should be provided in the indicated spaces using the appropriate two digit code. A listing of codes for use with this form is included in the Use Codes section of the How To Report chapter in the Environment Canada guideline document, Reporting For The Domestic Substances List.

CONFIDENTIALITY STATEMENTS

Information respecting substances disclosed to Environment Canada on the front of this form may be claimed confidential by checking the appropriate box(es) in Block V under Confidentiality Claims. This will indicate the applicability of the following statement(s):

1. Corporation: The link of this substance to the corporation identified in Block II is confidential;

2. Site of Manufacture: The link of this substance to the site of manufacture identified in Block III, or at any sites indicated on any attachment provided with this form, is confidential;

3. Manufacture: The fact that the corporation identified in Block II manufactures the substance for commercial purposes at the site identified in Block 111, or at any site indicated on any attachment provided with this form, is confidential;

4. Import: The fact that the corporation identified in Block II imports the substance for commercial purposes is confidential;

5. In Commerce: The fact that the corporation identified in Block II uses the substance in commerce is confidential;

6. Amount: The amount of this substance, as indicated by the amount code entered in Block V, that is imported, manufactured or used in commerce by the corporation identified in Block II is confidential;

7. Use: The fact that the corporation identified in Block II uses the substance for the purposes indicated by the use codes entered in Block V is confidential;

8. Substance Identity: The identity of this substance is confidential.

NOTE: If the identity of the substance is claimed confidential, the box beside "Substance Identity is Confidential" must be checked. In addition, a written substantiation for such a claim and a proposed masked name for the substance identified in Block V must be provided.

Criteria for Confidentiality

1. The information is confidential to the Company;

2. The Company has taken, and intends to continue to take, measures that are reasonable in the circumstances to maintain the confidentiality of the information;

3. The information is not, and has not been, reasonably obtainable by third persons by use of legitimate means except with the consent of the Company;

4. The information is not available to the public;

5. Disclosure of the information may reasonably be expected to cause substantial harm to the competitive position of the Company;

6. Disclosure of the information may reasonably be expected to result in a material financial loss to the Company or a material financial gain to the Company's competitors.

The protection of the information claimed to be confidential on this form will be consistent with the provisions of the access to information act and section 344 of the Canadian Environmental Protection Act, 1999.