Ozone-Depleting Substances Regulations

EnvironmentEnvironnementOzone-depleting Substances Regulations, 1998

CanadaCanadaClause 7(2)(b)(ii.1)(C) and,Form 5.7.1

subparagraph 33(1)(b.1)(ii) and,

paragraph 33(1)(b.2)

Declaration forUse of Methyl Bromide for a Purpose

Set Out in Paragraph 5(e) or (f) of Schedule 3

The application is for the year:

Section 1 - Applicant information

Name of person submitting this declaration (e.g. corporation):Telephone no.:

Address:Fax no. (if applicable):

City:Province:Postal Code:

Name of the person authorized to act on behalf ofTelephone no.

person submitting this declaration in Canada:in Canada:

Address in Canada:Fax no. in Canada (if applicable):

City:Province:Postal Code:

Section 2 – Information respecting the vendor/supplier

Name of vendor/supplier (e.g. corporation): Telephone no.:

Address:Fax no. (if applicable):

City:Province:Postal Code:

Name of person authorized to act on behalf ofTelephone no.

the vendor/supplier in Canada:in Canada:

Address in Canada:Fax no. in Canada (if applicable):

City:Province:Postal Code:

Section 3 - Information respecting the methyl bromide

Trade Name / Name of substance / Purpose set out in Schedule 3 / Total quantity of substance
(kilogram) / % of Methyl Bromide in mixture / Total quantity of Methyl Bromide (kilogram) / ODP / Calculated level (kilogram)
______
______/ ______
______/ ______
______/ ______
______/ ______X 0.6 = ______
______X 0.6 = ______

Section 4–Information respecting the recipient (or user, if applicable) and themethyl bromide to be sold or otherwise supplied

Name and address of the recipientQuantity soldCalculated

(or user, if applicable)or suppliedODPlevel

(kilogram)(kilogram)

X0.6=

Section 5 – Declaration and signature

I undertake not to sell or otherwise supply any of the quantity of methyl bromideacquired for a purpose set out in this application to any person who has not signed a declaration in the form set out in Form 5.7.1 to the Regulations.

I also undertake to use any of the methyl bromideacquired for the purpose set out in this application.

I declare that this declaration does not contain false or misleading information and that the recipienthas complied with Canadian law applicable in respect of the group of controlled substances.

Date, placeSignature of applicant or person authorized to act on behalf of applicant

ODS 5.7.1 (0803) 1 of 2