Environment
Canada
Ozone-depleting Substances Regulations, 1998
Subsection 16(1)
Form 5.11
Environnement
Canada
Annual Report (Controlled Substances Other Than Recovered, Recycled,
Reclaimed or Used Controlled Substances)
(One report for each controlled substance or for each authorized sector of HCFCs)
The report is for the year:
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):
For Environment Canada Use
City:
Province:
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 year. If checked, you need not fill in what follows other than the signature, date and place.
Section 3 - Information respecting the controlled substance or, the product that contains or is designed
to contain a controlled substance (attach supplementary sheets if necessary)
1) Group of controlled substances (check only one):
1
2
Tetrachloromethane
7
Hydrobromofluorocarbons
1,1,1-trichloroethane
8
Methyl Bromide
3
,4
Chlorofluorocarbons
9
Hydrochlorofluorocarbons
5
,6
Bromofluorocarbons
10
Bromochloromethane (Halon 1011)
2) If for Group 9 (HCFC), what is the authorized sector for which manufacture or import occurred (check only one):
Cooling, whether refrigeration or air-conditioning
Use in any other application
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 5.11 (0803)
www.ec.gc.ca/ozone/index.htm
Page 1 of 4
Environment
Canada
Ozone-depleting Substances Regulations, 1998
Subsection 16(1)
Form 5.11
Environnement
Canada
Section 4 – HCFC consumption allowance for the year
– HCFCs ONLY–
Calculated level
(kilogram)
Baseline consumption allowance
subsection 10(4) of the Ozone-depleting Substances Regulations, 1998 (Regulations):
Or, if baseline consumption allowances have not been allocated:
Initial consumption allowance subsections 10(3) and (3.01) of the Regulations:
Permits paragraph 33(1)(d) of the Regulations:
Adjustment to consumption allowance subsection 11(1) of the Regulations:
+
+
Transfer of consumption allowance TO other persons section 12 of the Regulations:
-
Transfer of consumption allowance FROM other person section 12 of the Regulations:
+
Consumption allowance for the year:
Note: Express all allowances, relevant adjustments and permit in calculated levels
=
– HCFCs ONLY–
Section 5 – HCFC consumption for the year
1. Production of HCFCs
(Exclude production for purpose set out in Schedule 3 for which a permit has been issued, report those at Section 6)
Quantity
Calculated
Controlled substance
manufactured
ODP
level
(kilogram)
(kilogram)
X
=
X
=
Total (1)
=
2. Destruction of HCFCs by technologies approved by the Parties
Name and address of
facility where substance
was destroyed
Controlled
substance
Technology used
for destruction
Quantity
destroyed
(kilogram)
Calculated
level
(kilogram)
ODP
X
=
X
=
Total (2) =
3. Use of HCFCs as feedstock
Controlled substance
Name and address of facility where
substance was used as a feedstock
Quantity
used
(kilogram)
Calculated
level
(kilogram)
ODP
X
=
X
=
Total (3) =
ODS 5.11 (0803)
www.ec.gc.ca/ozone/index.htm
Page 2 of 4
Environment
Canada
Ozone-depleting Substances Regulations, 1998
Subsection 16(1)
Form 5.11
Environnement
Canada
4. Importations of HCFCs
(Exclude imports for purpose set out in Schedule 3 for which a permit has been issued, report those in Section 6)
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
Total quantity of
controlled
substance
(kilogram)
ODP of
controlled
substance
Calculated
level
(kilogram)
___________
_____
__________
_______
_____________
________________
______________
X _________
=
___________
___________
_____
__________
_______
_____________
________________
______________
X _________
=
___________
___________
_____
__________
_______
_____________
________________
______________
X _________
=
___________
Total (4) =
*Canada Customs Coding Form B3 (14 digits)
5. Exportations of HCFCs
(Exclude exports for purpose set out in Schedule 3, report those in Section 6)
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
Calculated
level
(kilogram)
___________
_____
__________
__________
_____________
_______________
______________
X _________
=
__________
___________
_____
__________
__________
_____________
_______________
______________
X _________
=
__________
___________
_____
__________
__________
_____________
_______________
______________
X _________
=
__________
Total (5) =
*Canada Customs Coding Form B13 (14 digits)
CALCULATED LEVEL OF CONSUMPTION FOR THE YEAR: (1) - (2) - (3) + (4) - (5)
kg
Section 6 – Substances controlled by permits, for a purpose set out in Schedule 3 (attach supplementary
sheets if necessary)
1. Production for a purpose set out in Schedule 3
Purpose set out
in Schedule 3
Controlled substance
Quantity
produced
(kilogram)
Calculated
level
(kilogram)
ODP
X
=
X
=
Total
=
2. Importation for a purpose set out in Schedule 3
Trade Name /
Name of
substance
Purpose set
out in
Schedule 3
Date
of
Import
Transaction
no. of B3*
Country
of origin
Total quantity of
substance
imported
(kilogram)
Controlled
substance and % in
mixture
Total
quantity of
controlled
substance
(kilogram)
___________
___________
_____
__________
_______
_____________
________________
__________ X _________ = _______
___________
___________
_____
__________
_______
_____________
________________
__________ X _________ = _______
___________
___________
_____
__________
_______
_____________
________________
__________ X _________ = ________
Total
*Canada Customs Coding Form B3 (14 digits)
ODS 5.11 (0803)
www.ec.gc.ca/ozone/index.htm
ODP of
controlled
substance
Calculated
level
(kilogram)
=
Page 3 of 4
Environment
Canada
Ozone-depleting Substances Regulations, 1998
Subsection 16(1)
Form 5.11
Environnement
Canada
3. Exportation for a purpose set out in Schedule 3
Trade Name /
Name of
substance
Purpose set
out in
Schedule 3
Date
of
Export
Transaction
no. of B3*
Country of
destination
Total quantity of
substance
imported
(kilogram)
Controlled
substance and % in
mixture
Total
quantity of
controlled
substance
(kilogram)
___________
___________
_____
__________
________
_____________
________________
__________ X _________ = _______
___________
___________
_____
__________
________
_____________
________________
__________ X _________ = _______
___________
___________
_____
__________
________
_____________
________________
__________ X _________ = _______
Total
*Canada Customs Coding Form B13 (14 digits)
ODP of
controlled
substance
Calculated
level
(kilogram)
=
4. Inventory of controlled substance for a purpose set out in Schedule 3
Controlled substance
Inventory – January 1st
of reporting year
(ODP kilogram)
Purpose set out
in Schedule 3
Inventory – December 31st
of reporting year
(ODP kilogram)
5. Information respecting the recipients and the quantities of a controlled substance sold or otherwise supplied for
purposes set out in Schedule 3
Controlled
substance
Name and address
of recipient
Purpose set out
in Schedule 3
Quantity sold
or supplied
(kilogram)
Calculated
level
(kilogram)
ODP
X
=
X
=
Section 7 – Information respecting the controlled substances or the product, referred to by subsection
21(1) of the Regulations that contains or is designed to contain a substance identified in that subsection
(attach supplementary sheets if necessary)
Controlled
substance
Name and address of
each recipient outside
Canada for each shipment
(including country)
Origin of
product*
Product
exported
Quantity
exported**
(kilogram)
ODP
X
Calculated
level
(kilogram)
=
*For example, the product manufacturer.
**Please indicate the total quantity of controlled substance contained or designed to be contained in the product shipment.
Section 8 – Declaration and signature
I declare that this report does not contain false or misleading information.
Date, place
ODS 5.11 (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
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