Environment
Canada
Ozone-depleting Substances Regulations, 1998
Subsection 16(1)
Form 5.12
Environnement
Canada
Quarterly Report (Recovered, Recycled,
Reclaimed or Used Controlled Substances)
(One report for each group of controlled substances)
The report is for the year:
This report is for the quarter (check only one): Jan. – Mar.
Apr. – Jun.
Jul. – Sep.
Oct. – Dec.
Section 1 - Applicant information
Name of person submitting this report (e.g. corporation):
Telephone no.:
Address:
Fax no. (if applicable):
City:
Province:
Postal Code:
Name of the person authorized to act on behalf of
person submitting this report in Canada:
Telephone no.
in Canada:
Address in Canada:
Fax no. in Canada (if applicable):
City:
Province:
For Environment Canada Use
Postal Code:
Section 2 – Involvement
The person submitting this report was not engaged in any of the activities involving a controlled substance mentioned in this report
during the specified quarter. If checked, you need not fill in what follows other than the signature, date and place.
Section 3 - Information respecting the group and condition of controlled substances
1) Group of controlled substances (check only one):
1
Tetrachloromethane
7
Hydrobromofluorocarbons
2
1,1,1-trichloroethane
8
Methyl Bromide
Hydrochlorofluorocarbons
3
,4
Chlorofluorocarbons
9
5
,6
Bromofluorocarbons
10
Bromochloromethane (Halon 1011)
2) Condition of the controlled substances (check only one):
Recovered
Reclaimed
Recycled
Used
3) For each controlled substance, list the information concerning commercial name, formulation and classification:
Controlled
substance
Commercial name
Formulation (wt% of
controlled substance
Canada Customs
classification no.*
*Classification number under the Harmonized Commodity Description and Coding System as set out in the Customs Tariff (10 digits)
ODS 5.12 (0803)
www.ec.gc.ca/ozone/index.htm
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Environment
Canada
Ozone-depleting Substances Regulations, 1998
Subsection 16(1)
Form 5.12
Environnement
Canada
Section 4 – Exports
1. Calculated level of exports for this quarter of recovered, recycled, reclaimed or used controlled substance:
[Include all quantities reported in items (1.a) and (1.b) below]
Trade Name /
Name of
substance
Date
of
Export
Transaction
no. of B3*
Country of
destination
Total quantity of
substance
exported
(kilogram)
Controlled
substance and %
in mixture
Total quantity of
controlled
substance
(kilogram)
ODP of
controlled
substance
___________
_____
__________
__________
_____________
_______________
______________
X _________
=
__________
___________
_____
__________
__________
_____________
_______________
______________
X _________
=
__________
___________
_____
__________
__________
_____________
_______________
______________
X _________
=
__________
Total (including 1.a+1.b)
*Canada Customs Coding Form B13 (14 digits)
Calculated
level
(kilogram)
=
1.a Calculated level of exports for reclamation:
Controlled
substance
Name and address of facility
where substance was reclaimed
Technology used
for reclamation
Quantity
reclamed
(kilogram)
Calculated
level
(kilogram)
ODP
X
=
X
=
Total (1.a) =
1.b Calculated level of exports for destruction:
Controlled
substance
Name and address of facility
where substance was destroyed
Technology used
for destruction
Quantity
destroyed
(kilogram)
Calculated
level
(kilogram)
ODP
X
=
X
=
Total (1.b) =
Section 5 – Imports
1. Calculated level of imports for this quarter of recovered, recycled, reclaimed or used controlled substance:
(Include all quantities reported in items (1.a) and (1.b) below)
Trade Name /
Name of
substance
Date
of
Import
Transaction
no. of B3*
Country
of origin
Total quantity of
substance
imported
(kilogram)
Controlled
substance and % in
mixture
___________
_____
__________
_______
_____________
________________
______________
X _________
=
___________
___________
_____
__________
_______
_____________
________________
______________
X _________
=
___________
___________
_____
__________
_______
_____________
________________
______________
X _________
=
___________
*Canada Customs Coding Form B3 (14 digits)
ODS 5.12 (0803)
Total quantity of
controlled
substance
(kilogram)
ODP of
controlled
substance
Total (including 1.a+1.b)
www.ec.gc.ca/ozone/index.htm
Calculated
level
(kilogram)
=
Page 2 of 3
Environment
Canada
Ozone-depleting Substances Regulations, 1998
Subsection 16(1)
Form 5.12
Environnement
Canada
1.a Calculated level of imports for reclamation:
Controlled
substance
Name and address of facility
where substance was reclaimed
Technology used
for reclamation
Quantity
destroyed
(kilogram)
Calculated
level
(kilogram)
ODP
X
=
X
=
Total (1.a) =
1.b Calculated level of imports for destruction:
Controlled
substance
Name and address of facility
where substance was destroyed
Technology used
for destruction
Quantity
destroyed
(kilogram)
Calculated
level
(kilogram)
ODP
X
=
X
=
Total (1.b) =
Section 6 – Information respecting each recipient of each shipment
Controlled substance
Name and address
of recipient
Quantity to be sold or
supplied to each recipient
(kilogram)
Calculated
level
(kilogram)
ODP
X
=
X
=
X
=
X
=
Total
=
Section 7 – Declaration and signature
I declare that this report does not contain false or misleading information.
Date, place
ODS 5.12 (0803)
Signature of person submitting this report or person authorized
to act on behalf of person submitting this report
www.ec.gc.ca/ozone/index.htm
Page 3 of 3