Annual Report Form. Holder of a Permit for the Transportation of Residual Hazardous Materials to a Disposal Site

-Annual Management Report-

Transport of Residual Hazardous Materials to a Disposal Site

Legal References:Environment Quality Act, R.S.Q., Chapter Q-2, section 70.9

Hazardous Materials Regulation, Chapter Q-2, r.32*, sections 130, 134, and 137

Firm Identification

Ministerial no.: / CIDREQ1 no.:
Firm name:
Permit no.: / Permit expiry date:
Registered Firm Address / Postal Address (if different)
No.: / No.:
Street: / Street:
P.O. Box:
Municipality: / Municipality:
Province or State: / Province or State:
Postal Code or Zip: / Postal Code or Zip:
Name of Person in charge:
Phone no.: / Date:
E-mail:
Calendar Year

* Due to a change to regulation numbering that followed adoption of the Act respecting the Compilation of Québec Laws and Regulations, RSQ, c R-2.2.0.0.2, regulation # Q-2, r.32 henceforth replaces former regulation # Q-2, r.15.2.

1This number correspond’s to the number attributed to your firm by Centre informatique du registre des entreprises du Québec (CIDREQ) and registered with the Inspector General of Financial Institutions(IGFI).

List of Residual Hazardous Materials Transported during the Year

Must be filled only if the RHM was generated in Québec
Identification Code of Hazardous Materials described in Section 2 of Schedule 4 of the HMR / To be filled in all cases
RHM generated in Québec and Canada
Regulation designation from TDGR
(Column I of list  of Schedule ) / To be filled in all cases
RHM generated in Québec and Canada
PIN from TDGR
(Column III of list  of Schedule )
RHM generated outside Canada
Regulation designation from REIDD
(Column I of parts I, II, III or IV of Schedule 3) / RHM generated outside Canada
PIN from REIDD
(Column II of parts I, II, III or IV of Schedule 3)
Example: E09 4.3 S / Aluminum by-product / UN 3170

For each category of hazardous materials listed, please complete the tables on pages 3 and 4.

Identification Code of Hazardous Materials as provided in section 2 of Schedule 4, or the PIN assigned under the TDGR in accordance with RHM origin

Residual Hazardous Materials Received from Each Consignor

Consignors / Quantity transported
(Kg)
Firm Name
Address: No. and Street
City, Province (State)
Postal Code (Zip)
Firm Name
Address: No. and Street
City, Province (State)
Postal Code (Zip)
Firm Name
Address: No. and Street
City, Province (State)
Postal Code (Zip)
Firm Name
Address: No. and Street
City, Province (State)
Postal Code (Zip)
Firm Name
Address: No. and Street
City, Province (State)
Postal Code (Zip)
Firm Name
Address: No. and Street
City, Province (State)
Postal Code (Zip)
Identification Code of Hazardous Materials as provided in section 2 of Schedule 4, or the PIN assigned under the TDGR in accordance with RHM origin

Residual Hazardous Materials Delivered to a Disposal Site2

Consignees / Quantity delivered
(Kg)
Firm Name
Address: No. and Street
City, Province (State)
Postal Code (Zip)
Firm Name
Address: No. and Street
City, Province (State)
Postal Code (Zip)
Firm Name
Address: No. and Street
City, Province (State)
Postal Code (Zip)

2 In Québec, there are only 2 consignees operating a disposal site: Laidlaw at Ville Mercier, and Stablex at Blainville.

Our firm did not transport any residual hazardous material to a disposal site this year.

I hereby certify that the information provided in this Annual Management Report is complete and true.

Signature / Date

Please send back the form to the following address:

Ministère du Développement durable,de l’Environnement

et de la Lutte contre les changements climatiques

Direction des matières dangereuses et des pesticides

675, boul. René-Lévesque Est

9e étage, Boîte 71

Québec (Québec) G1R 5V7

Ministère du Développement durable, de l’Environnement et de la Lutte contre les changements climatiques1