Canada Gazette, Part I, Volume 146, Number 22: SUPPLEMENT

June 2, 2012

DEPARTMENT OF THE ENVIRONMENT

CANADIAN ENVIRONMENTAL PROTECTION ACT, 1999

Notice requiring the preparation and implementation of pollution prevention plans in respect of Cyclotetrasiloxane, octamethyl- (siloxane D4) in industrial effluents

Pursuant to section 91 of the Canadian Environmental Protection Act, 1999 (hereinafter referred to as the “Act”), the Minister of the Environment published in the Canada Gazette, Part Ⅰ, on January 15, 2011, the Proposed notice requiring the preparation and implementation of pollution prevention plans in respect of Cyclotetrasiloxane, octamethyl- (siloxane D4) in industrial effluents.

Whereas persons were given the opportunity to file comments with respect to the proposed Notice for a comment period of 60 days;

Whereas the Minister of the Environment has considered all comments received; and

Whereas the risk management objective of this Notice is to reduce total siloxane D4 releases to the aquatic environment from the sum of all persons subject to the Notice by 80%, from the preparation year levels, by the end of the implementation period,

Notice is hereby given that, pursuant to the provisions of Part 4 of the Act, the Minister of the Environment requires any person described in section 2 of the Notice to prepare and implement a pollution prevention plan in respect of Cyclotetrasiloxane, octamethyl-, which is specified on the List of Toxic Substances in Schedule 1 of the Act.

More information on pollution prevention planning can be found in the Pollution Prevention Planning Provisions of Part 4 of the Canadian Environmental Protection Act, 1999:Guidelines for Implementation. These guidelines and other information related to pollution prevention and pollution prevention planning can be found in the “Pollution Prevention Planning” section of Environment Canada’s Web site at www.ec.gc.ca/planp2-p2plan.

PETER KENT
Minister of the Environment

NOTICE REQUIRING THE PREPARATION AND IMPLEMENTATION OF POLLUTION PREVENTION PLANS IN RESPECT OF CYCLOTETRASILOXANE, OCTAMETHYL-
(SILOXANE D4) IN INDUSTRIAL EFFLUENTS

1. Definitions

The definitions in this section apply to this Notice.

“Act” means the Canadian Environmental Protection Act, 1999 (CEPA 1999).

“Calendar year” refers to a complete year beginning January 1 and ending December 31.

“D4” means Cyclotetrasiloxane, octamethyl-, Chemical Abstracts Service (CAS) (see footnote 1) Registry Number 556-67-2.

“Effluent” means process wastewater released at any final discharge point of the industrial facility.

“Final discharge point” is an identifiable discharge point beyond which the industrial facility owner or operator no longer exercises control over quality of the effluent.

“Minister” means the Minister of the Environment.

“Normal operating conditions” mean conditions representative of regular or typical operating conditions related to the manufacture or use of D4.

“Notice” means the Notice requiring the preparation and implementation of pollution prevention plans in respect of Cyclotetrasiloxane, octamethyl- (siloxane D4) in industrial effluents.

“Plan” means a pollution prevention plan.

2. Persons required to prepare and implement a plan

(1) The Notice applies to any person who owns or operates an industrial facility that, during the calendar year 2011 or any time thereafter, meets all the following criteria:

(a) Manufactures or uses D4, or a mixture containing D4, where the total quantity of D4 manufactured or used is equal to or greater than 100 kg per calendar year; and
(b) As a result of the manufacture or use of D4 or a mixture containing D4, releases an effluent containing D4 at any final discharge point of the facility.

(2) The Notice applies to any person who is the successor or assign of the persons identified in subsection 2(1).

(3) Despite subsection 2(1), the Notice does not apply to any person who owns or operates a facility that

(a) releases an effluent containing D4 in a concentration that is less than or equal to 17.3 µg/L at all final discharge points of the facility on the date the Notice is published and any time thereafter; or
(b) uses D4 exclusively as contained in a mixture in a concentration of less than 1% or in any solid material, including rubber, wiring insulation and seals for automobiles.

3. Activities in relation to which the plan is to be prepared

The Minister requires all persons identified in section 2 of the Notice to prepare and implement a plan in relation to the release of D4 in effluents through

(a) the manufacture of D4; or
(b) the use of D4 or a mixture that contains D4.

4. Factors to consider in preparing the plan

The Minister requires all persons identified in section 2 of the Notice to consider the following factors when preparing their plan:

(1) D4 was declared toxic under paragraph 64(a) of the Act and has been added to Schedule 1 of the Act. According to the final Screening Assessment Report, D4 is entering or may be entering the environment in a quantity or concentration or under conditions that have or may have an immediate or long-term harmful effect on the environment or its biological diversity. The final Screening Assessment Report also concluded that D4 meets the criterion for persistence as set out in the Persistence and Bioaccumulation Regulations.

(2) The reduction target for a person identified in section 2 is to achieve and maintain either

(a) a total D4 concentration in effluent at final discharge point(s) of the facility, through methods other than dilution, that is less than or equal to 17.3 μg/L; or
(b) a total quantity of D4 released in industrial effluent at final discharge point(s) of the facility that is less than or equal to 3 kg/year.

(3) Sampling and analysis should be completed as described below:

(a) The samples should be representative of the highest expected concentration of D4 at the final discharge point(s) resulting from normal operating conditions;
(b) Samples should be collected and analyzed at a minimum of four times per year at each final discharge point; and
(c) Analysis of samples should be performed in accordance with generally accepted standards of good scientific practice at the time of the analysis and by a laboratory that is accredited by a Canadian accrediting body under the International Organization for Standardization standard ISO/IEC 17025: 2005 titled General Requirements for the Competence of Testing and Calibration Laboratories, as amended from time to time. Analysis of samples can also be performed by a laboratory that is not accredited but that uses an analytical method that meets the minimum following criteria:
1. (i) Method Detection Limit: 2 μg/L
2. (ii) Accuracy: 30%
3. (iii) Precision: 30%

(4) In preparing a plan, a person subject to the Notice is to give priority to pollution prevention activities. “Pollution prevention” (P2), as defined in section 3 of the Act, means “the use of processes, practices, materials, products, substances or energy that avoid or minimize the creation of pollutants and waste and reduce the overall risk to the environment or human health.”

(5) The use of alternatives to D4 should be considered to reduce or minimize environmental and human health risks.

(6) Additional documents that should be kept with the plan:

(a) a description and the location (maps) of all final discharge points; and
(b) a description of the factors (e.g. type of technology, human factor, accidental releases, type of manufacturing, daily use) that could increase the quantity or concentration of the substance in the facility’s effluent.

(7) The implementation of the plan should include one year of monitoring which involves sampling and analysis at the final discharge point(s) after the reduction target set out in subsection 4(2) is achieved. Sampling and analysis should be conducted as specified in subsection 4(3).

(8) The Minister will measure the performance of the Notice, throughout the preparation and implementation periods, in order to determine its effectiveness in meeting the risk management objective and achieving the reduction target set out in subsection 4(2) of the Notice. This monitoring will be one of the elements considered by the Minister in order to determine whether additional measures, including regulations, may be required.

5. Period within which the plan is to be prepared

(1) For a person subject to the Notice on the date of publication in the Canada Gazette, Part Ⅰ, the Minister requires that the plan be prepared and implementation initiated no later than June 1, 2013.

(2) For a person becoming subject to the Notice after the date of publication in the Canada Gazette, Part Ⅰ, the Minister requires that the plan be prepared and implementation initiated no later than 12 months from becoming subject to the Notice.

6. Period within which the plan is to be implemented

(1) For a person subject to the Notice on the date of publication in the Canada Gazette, Part Ⅰ, the Minister requires that the plan be implemented no later than June 1, 2017.

(2) For a person becoming subject to the Notice after the date of publication in the Canada Gazette, Part Ⅰ, the Minister requires that the plan be implemented no later than 60 months from becoming subject to the Notice.

7. Content of plan

A person identified in section 2 of the Notice is to determine the appropriate content of that person’s plan; however, the plan must meet all the requirements of the Notice. The plan must also contain the information required to file the Declaration of Preparation referred to in section 9 of the Notice and have the capacity to generate the information required to file the Declaration of Implementation referred to in section 10 and the Interim Progress Reports referred to in section 12 of the Notice.

8. Requirement to keep plan and record keeping

Under section 59 of the Act, any person identified in section 2 of the Notice must keep a copy of the plan at the place in Canada in relation to which the plan is prepared. Where a single plan is prepared for more than one facility, a copy of that plan must be kept at each location.

Any person identified in section 2 of the Notice must keep the plan and any records pertaining to the plan for a minimum of five years following the period referred to in section 6 of the Notice.

9. Declaration of Preparation

Under subsection 58(1) of the Act, any person identified in section 2 of the Notice must file, within 30 days after the end of the period within which the plan is to be prepared as specified in section 5 or extended under section 14, a written “Declaration That a Pollution Prevention Plan Has Been Prepared and Is Being Implemented — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 58(1) of CEPA 1999).” This Declaration must be submitted to the Minister, using the form that the Minister provides and that contains the information set out in Schedule 1 of the Notice. Where a person has prepared a single plan for several facilities, a separate Declaration of Preparation must be filed for each facility.

10. Declaration of Implementation

Under subsection 58(2) of the Act, any person identified in section 2 of the Notice must file, within 30 days after the end of the period within which the plan is to be implemented as specified in section 6 or extended under section 14, a written “Declaration That a Pollution Prevention Plan Has Been Implemented — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 58(2) of CEPA 1999).” This Declaration must be submitted to the Minister, using the form that the Minister provides and that contains the information set out in Schedule 5 of the Notice. Where a person has prepared a single plan for several facilities, a separate Declaration of Implementation must be filed for each facility.

11. Filing of amended declarations

Under subsection 58(3) of the Act, where a person specified in section 2 of the Notice has filed a Declaration of Preparation or a Declaration of Implementation, referred to in sections 9 and 10 of the Notice, and the Declaration contains information that, at any time after the filing, has become false or misleading, that person must file an amended Declaration to the Minister within 30 days after the time that the information became false or misleading, using the appropriate form referred to in section 9 or 10 of the Notice.

12. Interim Progress Reports

A person identified in section 2 of the Notice must file to the Minister, on or before each of the dates below, a written “Interim Progress Report — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents,” using the form that the Minister provides and that contains the information set out in Schedule 4 of the Notice. If a Declaration of Implementation is submitted before an Interim Progress Report is due, the requirement to submit such an Interim Progress Report is nullified.

(1) For a person subject to the Notice on the date of publication in the Canada Gazette, Part Ⅰ,

Interim Progress Report No. 1 — deadline: July 1, 2014;
Interim Progress Report No. 2 — deadline: July 1, 2015; and
Interim Progress Report No. 3 — deadline: July 1, 2016.

(2) For a person becoming subject to the Notice after the date of publication in the Canada Gazette, Part Ⅰ,

Interim Progress Report No. 1 — deadline: 25 months from the date of becoming subject to the Notice;
Interim Progress Report No. 2 — deadline: 37 months from the date of becoming subject to the Notice; and
Interim Progress Report No. 3 — deadline: 49 months from the date of becoming subject to the Notice.

13. Use of a plan prepared or implemented for another purpose

Under subsection 57(1) of the Act, a person may use a pollution prevention plan prepared or implemented for another purpose to satisfy the requirements of sections 2 to 8 of the Notice. Under subsection 57(2) of the Act, where a person uses a plan that does not meet all the requirements of the Notice, the person must either amend the plan so that it meets all of those requirements or prepare an additional plan that meets the remainder of those requirements. Persons using existing plans must still file the Declaration of Preparation referred to in section 9 of the Notice, the Declaration of Implementation referred to in section 10 of the Notice, and any amended declarations under section 11 of the Notice, where applicable, and any Interim Progress Reports required under section 12 of the Notice.

14. Extension of time

Under subsection 56(3) of the Act, where the Minister is of the opinion that further time beyond the period referred to in section 5 of the Notice is needed to prepare the plan, or that further time beyond the period referred to in section 6 of the Notice is needed to implement the plan, the Minister may extend the period for a person who submits a written “Request for Time Extension — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 56(3) of CEPA 1999).” The written request must be submitted using the form that the Minister provides, contain the information set out in Schedule 3 of the Notice, and be made before the expiry of the date referred to in the applicable section 5 or section 6 of the Notice or before the expiry of any extended period.

15. Application for waiver of factors to consider

Under subsection 56(5) of the Act, the Minister may waive the requirement for a person to consider a factor in preparing the plan specified in section 4 of the Notice where the Minister is of the opinion that it is neither reasonable nor practicable to consider that factor on the basis of reasons provided by that person when submitting a written “Request for Waiver of the Requirement to Consider a Factor or Factors — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 56(5) of CEPA 1999).” The written request must be submitted using the form that the Minister provides and contain the information set out in Schedule 2 of the Notice. Such a request must be made before the expiry of the period within which the plan is to be prepared as referred to in section 5 of the Notice or before the expiry of any extended period.

16. More information on pollution prevention planning

Additional information and guidance on preparing plans may be obtained from

the Pollution Prevention section of Environment Canada’s Web site (www.ec.gc.ca/p2);
the Pollution Prevention Planning section of Environment Canada’s Web site (www.ec.gc.ca/planp2-p2plan/);
the CEPA Environmental Registry (www.ec.gc.ca/lcpe-cepa); and
the Canadian Pollution Prevention Information Clearinghouse (www.ec.gc.ca/ccipp-cppic).

17. Notice Reference Code: P2D4

For administrative purposes, all communication with Environment Canada concerning the Notice should refer to reference code P2D4.

18. Public disclosure of information and forms

The Minister of the Environment intends to publish the information submitted in response to the Notice in Schedules 1, 4 and 5 in the Pollution Prevention Planning section of Environment Canada’s Web site.

Under section 313 of the Act, all persons submitting information to the Minister are entitled to submit a written request that specific information be treated as confidential. Persons submitting such a request should include the reasons for that request.

The Notice includes the following forms:

Schedule 1: Declaration That a Pollution Prevention Plan Has Been Prepared and Is Being Implemented — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 58(1) of CEPA 1999);

Schedule 2: Request for Waiver of the Requirement to Consider a Factor or Factors — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 56(5) of CEPA 1999);

Schedule 3: Request for Time Extension — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 56(3) of CEPA 1999);

Schedule 4: Interim Progress Report — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents; and

Schedule 5: Declaration That a Pollution Prevention Plan Has Been Implemented — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 58(2) of CEPA 1999).

Forms referred to in the Notice (Schedules 1 to 5) are published as part of the Notice and may be filled out electronically using the Pollution Prevention Planning Online Reporting Tool found on Environment Canada’s Web site at www.ec.gc.ca/planp2-p2plan.

For guidance on how to complete the Schedules (1 to 5), please refer to “Instructions for Completing the Schedules — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents” which can be found on Environment Canada’s Web site at www.ec.gc.ca/planp2-p2plan/default.asp?lang=En&n=51567C93-1.

19. Environment Canada contact information

For technical questions or comments about the Notice, please contact or send queries to

Bernard Madé
Director
Chemical Production Division
Environment Canada
351 Saint-Joseph Boulevard
Gatineau, Quebec
K1A 0H3
Telephone: 819-994-4404
Fax: 819-994-5030
Email: pgpc-cmp.dppc-cpd@ec.gc.ca

For more information about pollution prevention planning, please contact

Innovative Measures Section
Regulatory Innovation and Management Systems
Environment Canada
351 Saint-Joseph Boulevard
Gatineau, Quebec
K1A 0H3
Telephone: 819-994-0186
Fax: 819-953-7970
Email: LCPEPlansP2-CEPAP2Plans@ec.gc.ca

EXPLANATORY NOTE

(This note is not part of the Notice.)

Compliance with the Canadian Environmental Protection Act, 1999 (hereinafter referred to as the “Act”) is mandatory under subsection 272(1) of the Act. Subsection 272(2) of the Act defines the penalties for persons who commit offences under the Act. Subsections 273(1) and 273(2) further outline the terms and penalties of those persons providing false or misleading information. Penalties under both subsections 272(2) and 273(2) include fines of not more than $1 million, imprisonment for a term of not more than three years, or both.

The Act is enforced in accordance with the Compliance and Enforcement Policy for the Canadian Environmental Protection Act, 1999, available at www.ec.gc.ca/lcpe-cepa/default.asp?lang=En&n=5082BFBE-1. Suspected violations under the Act can be reported to the Enforcement Branch by email at environmental.enforcement@ec.gc.ca.

NOTE: Do not fill out this form as it appears in the Canada Gazette. Please contact Environment Canada for more information about electronic reporting, as provided in sections 18 and 19 of the Notice.

Schedule 1: Declaration That a Pollution Prevention Plan Has Been Prepared and Is Being Implemented — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 58(1) of CEPA 1999)

Notice Reference Code: P2D4

For guidance on how to complete this Declaration, please refer to the “Instructions for Completing the Schedules — Pollution Prevention Planning Notice in respect of Cyclotetrasiloxane, octamethyl- (siloxane D4) in Industrial Effluents.” These instructions can be found on the Pollution Prevention (P2) Planning section of Environment Canada’s Web site at www.ec.gc.ca/planp2-p2plan/default.asp?lang=En&n=51567C93-1.

Is this an amendment to a Declaration previously submitted? Yes No

If yes, please specify the amended parts and reasons below. In addition, please complete Parts 1.0 and 9.0 and any other parts of this Declaration for which previously reported information has become false or misleading. Previously reported information that is unchanged need not be resubmitted.

If no, please proceed to Part 1.0 of this Declaration.

Amendment Part(s)

Please specify the parts of the Declaration that you would like to amend.

Amendment Reason(s)

Please specify the reasons for each of the amendments that you would like to make.

1.0 Information on the Person Subject to the Notice

Name of the Person Subject to the Notice: _________________________

Facility Name: _______________________________________________

Street Address of Facility: ______________________________________

City: ______________________________________________________

Province/Territory: ___________________________________________

Postal Code: _______________________________________________

Telephone Number: _________________________________________
(with area code)

Email: ____________________________________________________

Mailing Address of Facility (if different from Street Address):

__________________________________________________________

City: ______________________________________________________

Province/Territory: ___________________________________________

Postal Code: _______________________________________________

National Pollutant Release Inventory ID (if no ID, leave blank):

_________________________________________________________

Six-digit North American Industry Classification System (NAICS) Code
(if no Code, leave blank): ______________________________

Facility Technical Contact: ____________________________________

Email: ___________________________________________________

Telephone Number: ________________________________________
(with area code)

Fax Number (if available): ___________________________________
(with area code)

Please enter the name of a General Contact for the facility. This contact information will be used by Environment Canada to correspond with your facility on items related to your submission, including your facility registration and password required for login and reporting online.

General Contact Information

First Name: ______________________________________________________

Last Name: ______________________________________________________

Email: ___________________________________________________________

Position/Job Title: _________________________________________________

Telephone Number: ________________________________________________
(with area code)

Fax Number (if available): ___________________________________________
(with area code)

2.0 Use of Plans Prepared or Implemented for Another Purpose

Is the Pollution Prevention Plan used to fulfill the obligations of the Notice:

a Pollution Prevention Plan that was previously prepared on a voluntary basis?

Yes No
a Pollution Prevention Plan that was previously prepared for another government or under another Act of Parliament?

Yes No

If yes, identify the other government requirement(s) or Act of Parliament.

Parts 3.0 through 7.0 must be completed separately for each Activity selected in Part 3.0 below.

3.0 Substance and Activity

Substance and Activity for which information is required (choose all those that apply):

Manufacture of D4 (see footnote 2)
Use of D4 or a mixture that contains D4

4.0 Baseline Information Prior to Implementation of the Pollution Prevention (P2) Plan

Notes:

a) Wherever possible, the data collected in Part 4 of this Declaration are consistent with the reporting requirements of the National Pollutant Release Inventory (NPRI).
b) In Part 4.0, where indicated, use the following Basis of Estimate Codes to describe how each quantity reported in this part of the Declaration was determined:
1. M1 Continuous Emission Monitoring Systems
2. M2 Predictive Emission Monitoring
3. M3 Source Testing
4. C Mass Balance
5. E1 Site-specific Emission Factor
6. E2 Published Emission Factor
7. O Engineering Estimates
8. X Other (please specify): ___________________________________________
c) This Declaration requires reporting of data from the 2012 Preparation Year (June 2, 2012, to June 1, 2013).

If you are reporting data for a year other than the above-specified year, check all of the situations that apply to you:

Person subject to the Notice has been granted a time extension to prepare a plan which results in a Preparation Year other than 2012

Person became subject to the Notice after the date of publication which results in a Preparation Year other than 2012

If either of the above is applicable, indicate the new Preparation Year for which you are reporting: ___________. Please provide your start and end dates representing one full year’s duration (e.g. 2015-07-23 to 2016-07-22): _________________ to ________________.

All references to the Preparation Year 2012 throughout this Declaration will be replaced by this new Preparation Year.

4.1 Nature of Activity and On-Site Uses/Manufacturing

For the activity identified in Part 3.0 of this Declaration, did this facility use or manufacture the substance on-site during the Preparation Year? Yes No

If no, proceed to Part 4.3 of this Declaration.

If yes, for the activity identified in Part 3.0 of this Declaration, please complete the table in Part 4.1.1 if the activity selected in Part 3.0 was “Manufacture of D4.” Please complete the tables in Part 4.1.2 (a) and (b) if the activity selected in Part 3.0 was “Use of D4 or a mixture that contains D4.” It should be noted that at least one nature of activity must be selected and more than one nature of activity may be selected.

4.1.1 Manufacture of D4

Indicate the nature of activity in relation with the manufacture of D4 at the facility for the Preparation Year. In addition, report the total quantity of D4 manufactured during the Preparation Year, in kilograms (kg), for these natures of activities and the Basis of Estimate Code (see Part 4.0, Note b) in the appropriate fields below.

Nature of Activity	Total Quantity of D4 Manufactured (kg)	Basis of Estimate Code
For on-site use/processing
For sale/distribution
As a by-product
As an impurity
Other
Total		n/a

If “Other” is selected, please provide a description: ___________________________

4.1.2 Use of D4 or a mixture that contains D4

4.1.2 (a) Nature of Activity

Indicate the nature of activity in relation with the use of D4 or a mixture that contains D4 at the facility for the Preparation Year. Also indicate the quantity (kg) of D4 used for the Preparation Year and the Basis of Estimate Code (see Part 4.0, Note b) in the appropriate fields below.

Nature of Activity	Total Quantity of D4 Used (kg)	Basis of Estimate Code
As a reactant
As a formulation component
As an article component
As a by-product
As a physical or chemical processing aid
As a manufacturing aid
For repackaging only
Other
Total		n/a

If “Other” is selected, please provide a description: __________________________

4.1.2 (b) Manufactured Product

Indicate the type of manufactured product resulting from the use of D4 or a mixture that contains D4 at the facility for the Preparation Year.

Types of Product Manufactured
Silicone polymers or copolymers
Personal care products
Adhesives or sealants
Paints or coatings
Pharmaceutical products
Soaps or cleaning compounds
Other

If “Other” is selected, please provide a description: __________________________

4.2 No data required for Part 4.2 of this Declaration

4.3 On-site Releases

For the activity identified in Part 3.0 of this Declaration, did this facility release effluents containing D4 at any final discharge point in the Preparation Year? Yes No

If no, proceed to Part 5.0 of this Declaration. If yes, proceed to Part 4.3.3.

4.3.1 Releases to Air — No data required for Part 4.3.1 of this Declaration

4.3.2 Underground Injection — No data required for Part 4.3.2 of this Declaration

4.3.3 Releases to Water

Report below the quantity of all releases of the substance to water in kg, for that year, and the Basis of Estimate Code (see Part 4.0, Note b) in the appropriate field below.

Type of Releases	Quantity of D4 Released for the Preparation Year (kg)	Basis of Estimate Code
a) Surface Water
b) Wastewater System
Total		n/a

4.3.4 Releases to Land — No data required for Part 4.3.4 of this Declaration

4.4 No data required for Part 4.4 of this Declaration

4.5 Additional Baseline Information

4.5.1 Sampling and Analysis

For the activity identified in Part 3.0 of this Declaration, indicate, for each sample collected, the location where the sample was collected (final discharge point of facility or other location), the date of the sampling and analysis, the laboratory name, city and phone number, the concentration of D4 in the sample collected (µg/L) and the estimated concentration of D4 (µg/L) at the final discharge point (when the sample is collected at another location than the final discharge point of the facility).

Please indicate the number of final discharge points for which you are reporting:

__________________________________________________________

For each final discharge point, indicate the number of samples collected:

__________________________________________________________

Final Discharge Point 1
Sample	Location Where the Sample Was Collected (check the appropriate box)		Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
Sample	Final Discharge Point	Other Location	Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
1
2
3
4

Final Discharge Point 2
Sample	Location Where the Sample Was Collected (check the appropriate box)		Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
Sample	Final Discharge Point	Other Location	Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
1
2
3
4

If less than four samples were collected for a final discharge point, please explain why.

If the samples were collected at a location other than the final discharge point of the facility, please justify and explain the relation with the final discharge point.

4.5.2 Details on Final Discharge Point(s) of the facility

For the activity identified in Part 3.0 of this Declaration, identify the type of release, the name and location of the surface waters or of the wastewater treatment plant (WWTP) associated to the wastewater system in which the industrial effluent is released at the final discharge point of the facility. If the effluent is released in an off-site wastewater system, indicate the type of treatment of the wastewater system if known.

Final Discharge Point	Type of Release (check the appropriate box)		Name of the Surface Waters or WWTP	Location (address or geographical coordinates)
Final Discharge Point	Surface Water	Wastewater System	Name of the Surface Waters or WWTP	Location (address or geographical coordinates)
1
2

5.0 Anticipated Actions and Results

5.1 Anticipated Action

Parts 5.1.1 through 5.1.6 must be completed separately for each anticipated action in the P2 plan, i.e. Part 5.1 will be completed as many times as there are anticipated actions to report.

In Part 5.1.1, describe, for the activity identified in Part 3.0 of this Declaration, the anticipated action to be taken in implementing the Pollution Prevention Plan. If the anticipated action includes the use of alternative substances, please include the chemical name, common name or CAS number of the substance. If the anticipated action includes the use of pollution control, please include a description of the pollution control method.

5.1.1 Anticipated Action

What is the current status of this Action?

Planned/To be initiated
In progress
Completed

For the anticipated action reported above, identify whether it represents a pollution prevention method mentioned in Part 5.1.2 OR an environmental protection method mentioned in Part 5.1.3.

5.1.2 Types of Pollution Prevention Methods:

For a detailed description of pollution prevention methods, please refer to the Pollution Prevention Planning Handbook (www.ec.gc.ca/planp2p-2plan/default.asp?lang=En&n=56875F44-1).

Material or feedstock substitution
Product design or reformulation
Equipment or process modifications
Spill and leak prevention
On-site reuse, recycling or recovery
Inventory management or purchasing techniques
Good operating practices or training
Other: _________________________________________

5.1.3 Types of Environmental Protection Methods:

Energy recovery
Off-site recycling
Incineration with energy recovery
Waste treatment
Pollution control
Disposal
Other: _________________________________________

In Part 5.1.4, report, where possible, the corresponding change in annual releases of the substance anticipated to be achieved by implementing that action in kg and μg/L. Indicate a decrease with a negative sign (“–”) and an increase with a positive sign (“+”) in front of the reported quantity. Note that estimating a quantitative change for some anticipated actions, such as employee training, may not be possible.

5.1.4 Anticipated Changes: _______________________________________

In Part 5.1.5, describe which elements of the Baseline Elements identified in Part 4.0 (see below) are affected by the changes reported in 5.1.4. Note that actions may affect more than one Baseline Element.

A = total quantity manufactured on-site
B = total quantity used on-site
C = total quantity released to water (surface waters or wastewater system)
D = effluent concentration at final discharge point(s)
E = other (If other is selected, please provide a short description.)

5.1.5 Baseline Elements Affected: _______________________________________

Finally, in Part 5.1.6, identify the planned completion date for the anticipated action.

5.1.6 Planned Completion Date (YYYY-MM-DD): _____________________________

This ends Parts 5.1.1 through 5.1.6 that must be completed separately for each anticipated action in the P2 plan.

5.2 No Data Required for Part 5.2 of this Declaration

5.3 Total Anticipated Results

The table below summarizes, for the activity identified in Part 3.0 of this Declaration, the total anticipated change in annual releases of the substance in kg, μg/L and as a percentage relative to the Preparation Year 2012.

Report the total anticipated changes to be achieved by implementing only the anticipated actions described in part 5.1 of this Declaration.

Important: Indicate a decrease with a negative sign (“–”) and an increase with a positive sign (“+”) in front of the reported quantity.

Type of Releases	Final Discharge Point	Total Anticipated Change (in concentration) Relative to the Preparation Year (μg/L)	Total Anticipated Change (in concentration) Relative to the Preparation Year (%)
On-site releases	1
	2
	Total	n/a	n/a

6.0 Monitoring and Reporting

Describe the anticipated monitoring and reporting that will be used to track progress in implementing the Pollution Prevention Plan.

7.0 Risk Management Objective

Describe how the Pollution Prevention Plan will meet the reduction target identified in subsection 4(2) of the Notice.

If you anticipate that this Plan will not meet the reduction target, explain why.

This ends Parts 3.0 through 7.0 of this Declaration to be completed separately for each Activity specified in Part 3.0 above.

8.0 Factors to Consider

Describe what was done by the person subject to the Notice to take into account the “Factors to Consider in Preparing the Plan” set out in subsections 4(3) to 4(7) of the Notice, except those factors for which a waiver has been granted by the Minister of Environment.

4(3) Sampling and Analysis activities

4(4) Use of Pollution Prevention

4(5) Use of Alternatives

4(6) Keep additional documents with the plan

4(7) One year of monitoring after meeting the reduction target (before the end of the implementation period)

9.0 Certification

I hereby certify that a Pollution Prevention Plan has been prepared and is being implemented in respect of Cyclotetrasiloxane, octamethyl- (siloxane D4) in industrial effluents and that the information provided in this Declaration is true, accurate and complete.

____________________________________________________________________

Signature of the Person Subject to the Notice or Duly Authorized Representative

____________________________________________________________________

Date

Name: _________________________________________________________

Please Print

Title/Position: ___________________________________________________

Please Print

NOTE: Do not fill out this form as it appears in the Canada Gazette. Please contact Environment Canada for more information about electronic reporting, as provided in sections 18 and 19 of the Notice.

Schedule 2: Request for Waiver of the Requirement to Consider a Factor or Factors — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 56(5) of CEPA 1999)

Notice Reference Code: P2D4

For guidance on how to complete this Request, please refer to the “Instructions for Completing the Schedules — Pollution Prevention Planning Notice in respect of Cyclotetrasiloxane, octamethyl- (siloxane D4) in Industrial Effluents.” These Instructions can be found on the Pollution Prevention (P2) Planning section of Environment Canada’s Web site at www.ec.gc.ca/planp2-p2plan/default.asp?lang=En&n=51567C93-1.

Is this an amendment to a Request previously submitted? Yes No

If yes, please specify the amended parts and reasons below. In addition, please complete Parts 1.0 and 4.0 and any other parts of this Request for which previously reported information has become false or misleading. Previously reported information that is unchanged need not be resubmitted.

If no, please proceed to Part 1.0 of this Request.

Amendment Part(s)

Please specify the parts of the Request that you would like to amend.

Amendment Reason(s)

Please specify the reasons for each of the amendments that you would like to make.

1.0 Information on the Person Subject to the Notice

Name of the Person Subject to the Notice: _________________________________

Facility Name: ________________________________________________________

Street Address of Facility: _______________________________________________

City: _______________________________________________________________

Province/Territory: ____________________________________________________

Postal Code: ________________________________________________________

Telephone Number: __________________________________________________
(with area code)

Email: _____________________________________________________________

Mailing Address of Facility (if different from Street Address):

___________________________________________________________________

City: _______________________________________________________________

Province/Territory: ____________________________________________________

Postal Code: ________________________________________________________

National Pollutant Release Inventory ID (if no ID, leave blank): _________________

Six-digit North American Industry Classification System (NAICS) Code
(if no Code, leave blank): _______________________________________________

Facility Technical Contact: _______________________________________________

Email: ______________________________________________________________

Telephone Number: ___________________________________________________
(with area code)

Fax Number (if available): ______________________________________________
(with area code)

General Contact Information

First Name: _______________________________________________

Last Name: _______________________________________________

Email: ____________________________________________________

Position/Job Title: __________________________________________

Telephone Number: _________________________________________
(with area code)

Fax Number (if available): _____________________________________
(with area code)

2.0 Factor(s) for Which a Waiver is Being Requested

Identify for which factor(s) listed in the Notice a waiver is being requested.

3.0 Rationale for Request

Explain why it would not be reasonable or practicable to consider each factor for which a waiver is being requested.

Explain how the outcome of the Pollution Prevention Plan will be affected if this or these “factor(s) to consider” is (are) not taken into account.

Identify which, if any, additional factor(s) you propose to consider in preparing the Pollution Prevention Plan (optional).

4.0 Certification

I hereby certify that the information provided in this Request in respect of Cyclotetrasiloxane, octamethyl- (siloxane D4) in industrial effluents is true, accurate and complete.

____________________________________________________________________

Signature of the Person Subject to the Notice or Duly Authorized Representative

____________________________________________________________________

Date

Name: ________________________________________________________

Please Print

Title/Position: ___________________________________________________

Please Print

Schedule 3: Request for Time Extension — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 56(3) of CEPA 1999)

Notice Reference Code: P2D4

For guidance on how to complete this Request, please refer to the “Instructions for Completing the Schedules — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents.” These Instructions can be found on the Pollution Prevention (P2) Planning section of Environment Canada’s Web site at www.ec.gc.ca/planp2-p2plan/default.asp?lang=En&n=51567C93-1.

Is this an amendment to a Request previously submitted? Yes No

If no, please proceed to Part 1.0 of this Request.

Amendment Part(s)

Please specify the parts of the Request that you would like to amend.

Amendment Reason(s)

Please specify the reasons for each of the amendments that you would like to make.

1.0 Information on the Person Subject to the Notice

Name of the Person Subject to the Notice: __________________________________

Facility Name: ________________________________________________________

Street Address of Facility: _______________________________________________

City: _______________________________________________________________

Province/Territory: ____________________________________________________

Postal Code: ________________________________________________________

Telephone Number: ___________________________________________________
(with area code)

Email: ______________________________________________________________

Mailing Address of Facility (If different than Street Address):

____________________________________________________________________

City: ________________________________________________________________

Province/Territory: _____________________________________________________

Postal Code: __________________________________________________________

National Pollutant Release Inventory ID (if no ID, leave blank): _________________

Six-digit North American Industry Classification System (NAICS) Code
(if no Code, leave blank): _______________________________________________

Facility Technical Contact: ________________________________________________

Email: _______________________________________________________________

Telephone Number: ____________________________________________________
(with area code)

Fax Number (if available): ________________________________________________
(with area code)

General Contact Information

First Name: ________________________________________________

Last Name: ________________________________________________

Email: _____________________________________________________

Position/Job Title: ___________________________________________

Telephone Number: __________________________________________
(with area code)

Fax Number (if available): ____________________________________
(with area code)

2.0 Request for Time Extension

Identify for which of the following a time extension is being requested (choose one):

to prepare a Pollution Prevention Plan
to implement a Pollution Prevention Plan

For the person identified in Part 1.0, it is requested that the date be extended to: _____________________ (specify exact date — YYYY-MM-DD)

3.0 Rationale for Request

Explain why additional time is needed to prepare or implement a Pollution Prevention Plan.

4.0 Certification

I hereby certify that the information provided in this Request in respect of Cyclotetrasiloxane, octamethyl- (siloxane D4) in industrial effluents is true, accurate and complete.

____________________________________________________________________

Signature of the Person Subject to the Notice or Duly Authorized Representative

____________________________________________________________________

Date

Name: ___________________________________________________________

Please Print

Title/Position: _____________________________________________________

Please Print

Schedule 4: Interim Progress Report — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents

Notice Reference Code: P2D4

Is this an amendment to a Report previously submitted? Yes No

If yes, please specify the amended parts and reasons below. In addition, please complete Parts 1.0 and 9.0 and any other parts of this Schedule for which previously reported information has become false or misleading. Previously reported information that is unchanged need not be resubmitted.

If no, please proceed to Part 1.0 of this report.

Amendment Part(s)

Please specify the parts of the Report that you would like to amend.

Amendment Reason(s)

Please specify the reasons for each of the amendments that you would like to make.

1.0 Information on the Person Subject to the Notice

Name of the Person Subject to the Notice: ___________________________________

Facility Name: _________________________________________________________

Street Address of Facility: ________________________________________________

City: ________________________________________________________________

Province/Territory: _____________________________________________________

Postal Code: _________________________________________________________

Telephone Number: ____________________________________________________
(with area code)

Email: _______________________________________________________________

Mailing Address of Facility (if different from Street Address):

_____________________________________________________________________

City: ________________________________________________________________

Province/Territory: _____________________________________________________

Postal Code: _________________________________________________________

National Pollutant Release Inventory ID (if no ID, leave blank): __________________

Six-digit North American Industry Classification System (NAICS) Code
(if no Code, leave blank): _______________________________________________

Facility Technical Contact: ______________________________________________

Email: ______________________________________________________________

Telephone Number: __________________________________________________
(with area code)

Fax Number (if available): ______________________________________________
(with area code)

General Contact Information

First Name: _______________________________________________________

Last Name: _______________________________________________________

Email: ___________________________________________________________

Position/Job Title: _________________________________________________

Telephone Number: ________________________________________________
(with area code)

Fax Number (if available): ___________________________________________
(with area code)

2.0 Use of Plans Prepared or Implemented for Another Purpose — No data is required for Part 2.0 of this Report

Parts 3.0 through 7.0 must be completed separately for each Activity selected in Part 3.0 below.

3.0 Substance and Activity

Substance and Activity for which information is required (choose all those that apply):

Manufacture of D4 (see footnote 3)
Use of D4 or a mixture that contains D4

4.0 Progress Information During Implementation of the Pollution Prevention (P2) Plan

The Preparation Year refers to the year identified in your Schedule 1 — Declaration That a Pollution Prevention Plan Has Been Prepared and Is Being Implemented — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents.

Notes:

a) Wherever possible, the data collected in Part 4.0 of this Report are consistent with the reporting requirements of the National Pollutant Release Inventory (NPRI).
b) In Part 4.0, where indicated, use the following Basis of Estimate Codes to describe how each quantity reported was determined:
1. M1 Continuous Emission Monitoring Systems
2. M2 Predictive Emission Monitoring
3. M3 Source Testing
4. C Mass Balance
5. E1 Site-specific Emission Factor
6. E2 Published Emission Factor
7. O Engineering Estimates
8. X Other (Please specify): ____________________________________

c) If the person is subject to the Notice on the date of publication of the Notice in the Canada Gazette, the Notice requires reporting of data in an Interim Progress Report for the following years:
Interim Progress Report	Reporting Year	Reporting Period
Interim Progress Report No. 1	2013	June 2, 2013, to June 1, 2014
Interim Progress Report No. 2	2014	June 2, 2014, to June 1, 2015
Interim Progress Report No. 3	2015	June 2, 2015, to June 1, 2016

Indicate the number of the Interim Progress Report for which you are reporting: ___________. Note that the Reporting Year associated with this Interim Progress Report Number is referred to as the Reporting Year throughout this Report).

If you are reporting data for a year other than the above-specified years, because either you have been granted a time extension to prepare a plan or you became subject to the Notice after the date of publication, which resulted in a Preparation Year other than 2012, indicate the new Reporting Year for which you are reporting: _________. In addition, please also provide the start and end dates representing one full year’s duration (e.g. 2015-07-23 to 2016-07-22): _____________________ to __________________________. Note that this is referred to as the Reporting Year throughout this Report.

4.1 Nature of Activity and On-Site Uses/Manufacturing

For the activity identified in Part 3.0 of this Report, did this facility use or manufacture the substance on-site in the Reporting Year? Yes No

If no, proceed to Part 4.3 of this Report.

If yes, please complete the table in Part 4.1.1 if the activity selected in Part 3.0 was “Manufacture of D4.” Please complete the tables in Part 4.1.2 (a) and (b) if the activity selected in Part 3.0 was “Use of D4 or a mixture that contains D4.” It should be noted that at least one nature of activity must be selected and more than one nature of activity may be selected.

4.1.1 Manufacture of D4

Indicate the nature of activity in relation with the manufacture of D4 at the facility for the Reporting Year. In addition, report the total quantity of D4 manufactured during the Reporting Year, in kilograms (kg), for these natures of activities and the Basis of Estimate Code (see Part 4.0, Note b) in the appropriate fields below.

Nature of Activity	Total Quantity of D4 Manufactured (kg)	Basis of Estimate Code
For on-site use/processing
For sale/distribution
As a by-product
As an impurity
Other
Total		n/a

If “Other” is selected, please provide a description: ___________________________

4.1.2 Use of D4 or a mixture that contains D4

4.1.2 (a) Nature of Activity

Indicate the nature of activity in relation with the use of D4 or a mixture that contains D4 at the facility for the Reporting Year. Also indicate the quantity (kg) of D4 used for the Reporting Year and the Basis of Estimate Code (see Part 4.0, Note b) in the appropriate fields below.

Nature of Activity	Total Quantity of D4 Used (kg)	Basis of Estimate Code
As a reactant
As a formulation component
As an article component
As a by-product
As a physical or chemical processing aid
As a manufacturing aid
For repackaging only
Other
Total		n/a

If “Other” is selected, please provide a description: __________________________

4.1.2 (b) Manufactured Product

Indicate the type of manufactured product resulting from the use of D4 or a mixture that contains D4 at the facility for the Preparation Year.

Types of Product Manufactured
Silicone polymers or copolymers
Personal care products
Adhesives or sealants
Paints or coatings
Pharmaceutical products
Soaps or cleaning compounds
Other

If “Other” is selected, please provide a description: ___________________________

4.2 No data required for Part 4.2 of this Declaration

4.3 On-site Releases

For the activity identified in Part 3.0 of this Report, did this facility release an effluent containing D4 at any final discharge point in the Reporting Year? Yes No

If no, proceed to Part 5.0 of this Report. If yes, proceed to Part 4.3.3.

4.3.1 Releases to Air — No data required for Part 4.3.1 of this Report

4.3.2 Underground Injection — No data required for Part 4.3.2 of this Report

4.3.3 Releases to Water

Report below the quantity of all releases of the substance to water, in kg, for that year, and the Basis of Estimate Code (see Part 4.0, Note b) in the appropriate field below.

Type of Release	Quantity of D4 Released for the Reporting Year (kg)	Basis of Estimate Code
a) Surface water
b) Wastewater system
Total		n/a

4.3.4 Releases to Land — No data required for Part 4.3.4 of this Report

4.4 No data required for Part 4.4 of this Report

4.5 Additional Progress Information

4.5.1 Sampling and Analysis

For the activity identified in Part 3.0 of this Report, indicate, for each sample collected, the location where the sample was collected (final discharge point of facility or other location), the date of the sampling and analysis, the laboratory name, city and phone number, the concentration of D4 in the sample collected (µg/L) and the estimated concentration of D4 (µg/L) at the final discharge point (when the sample is collected at another location than the final discharge point of the facility).

Please indicate the number of final discharge points for which you are reporting:

________________________________________________________________

For each final discharge point, indicate the number of samples collected:

________________________________________________________________

Final Discharge Point 1
Sample	Location Where the Sample Was Collected (check the appropriate box)		Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
Sample	Final Discharge Point	Other Location	Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
1
2
3
4

Final Discharge Point 2
Sample	Location Where the Sample Was Collected (check the appropriate box)		Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
Sample	Final Discharge Point	Other Location	Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
1
2
3
4

If less than four samples were collected for a final discharge point, please explain why.

If the samples were collected at a location other than the final discharge point of the facility, please justify and explain the relation with the final discharge point.

4.5.2 Details on Final Discharge Point(s) of the facility

For the activity identified in Part 3.0 of this Report, identify the type of release, the name and location of the surface waters or of the wastewater treatment plant (WWTP) associated to the wastewater system in which the industrial effluent is released at the final discharge point of the facility. If the effluent is released in an off-site wastewater system, indicate the type of treatment of the wastewater system (if known).

Final Discharge Point	Type of Release (check the appropriate box)		Name of the Surface Waters or WWTP	Location (address or geographical coordinates)
Final Discharge Point	Surface Water	Wastewater System	Name of the Surface Waters or WWTP	Location (address or geographical coordinates)
1
2

5.0 Action(s) Taken and Results Achieved to Date

5.1 Action(s) taken to date

Parts 5.1.1 through 5.1.6 must be completed separately for each action taken to date in the P2 plan, i.e. Part 5.1 will be completed as many times as there are actions taken to date to report.

In Part 5.1.1, describe, for the activity identified in Part 3.0 of this Report, the action taken to date in implementing the Pollution Prevention Plan. For the purpose of this Report, “to date” refers to the end of the reporting year as specified in Part 4.0c) of this Report. For the first Interim Progress Report, report actions taken since initiating the implementation of the Pollution Prevention Plan. For all subsequent Interim Progress Reports, report actions taken since filing of the previous Interim Progress Report. If the action taken to date includes the use of alternative substances, please include the chemical name, common name or CAS number of the substance. If action taken includes the use of pollution control, please include a description of the pollution control method.

5.1.1 Action taken to date

What is the current status of this Action?

Planned/To be initiated
In progress
Completed
Discontinued

If the action is “Discontinued,” please provide the reason why you will no longer be carrying out this action for the activity.

For the action taken reported above, identify whether it represents a pollution prevention method mentioned in Part 5.1.2 OR an environmental protection method mentioned in Part 5.1.3.

5.1.2 Types of Pollution Prevention Methods:

For a detailed description of pollution prevention methods, please refer to the Pollution Prevention Planning Handbook (www.ec.gc.ca/planp2-p2plan/default.asp?lang=En&n=56875F44-1).

Material or feedstock substitution
Product design or reformulation
Equipment or process modifications
pill and leak prevention
On-site reuse, recycling or recovery
Inventory management or purchasing techniques
Good operating practices or training
Other: ____________________________________________

5.1.3 Types of Environmental Protection Methods:

Energy recovery
Off-site recycling
Incineration with energy recovery
Waste treatment
Pollution control
Disposal
Other: ____________________________________________

In Part 5.1.4, report, where possible, the corresponding change in annual releases of the substance achieved to date by implementing that action in kg and μg/L. Indicate a decrease with a negative sign (“–”) and an increase with a positive sign (“+”) in front of the reported quantity. Note that estimating a quantitative change for some actions taken, such as employee training, may not be possible.

5.1.4 Changes Achieved to Date: ____________________________________

A = total quantity manufactured on-site
B = total quantity used on-site
C = total quantity released to water (surface waters or wastewater system)
D = effluent concentration at final discharge point(s)
E = other (If other is selected, please provide a short description.)

5.1.5 Baseline Elements Affected: _________________________________________

Finally, in Part 5.1.6, identify the planned completion date for the action taken.

5.1.6 Completion Date (YYYY-MM-DD): ______________________________________

This ends Parts 5.1.1 through 5.1.6 that must be completed separately for each action taken to date in the P2 plan.

5.2 No Data Required for Part 5.2 of this Report

5.3 Total Results Achieved To Date

The table below summarizes, for the activity identified in Part 3.0 of this Report, the total change achieved to date in annual releases of the substance in kg, μg/L and as a percentage relative to the Preparation Year, as reported in Schedule 1. For the purpose of the report, “to date” means the end of the reporting year as specified in Part 4.0c) of this Report.

Report the total changes achieved by implementing all actions taken to date described in part 5.1 of this Report.

Important: Indicate a decrease with a negative sign (“–”) and an increase with a positive sign (“+”) in front of the reported quantity.

Type of Releases	Final Discharge Point	Total Change Achieved (in concentration) Relative to the Preparation Year (μg/L)	Total Change Achieved (in concentration) Relative to the Preparation year (%)
On-site releases	1
	2
	Total	n/a	n/a

6.0 Monitoring and Reporting

Describe the monitoring and reporting used to track progress in implementing the Pollution Prevention Plan.

7.0 Risk Management Objective

Describe the progress or additional details on how the Pollution Prevention Plan will meet the reduction target identified in subsections 4(2) of the Notice.

If you anticipate that this Plan will not meet the reduction target, explain why.

This ends Parts 3.0 through 7.0 of this Report to be completed separately for each Activity specified in Part 3.0 above.

8.0 Factors to Consider

Describe any progress made in this Reporting Year towards taking into account the “Factors to Consider in Preparing the Plan” set out in subsections 4(3) to 4(7) of the Notice, except those factors for which a waiver has been granted by the Minister of the Environment.

4(3) Sampling and Analysis activities

4(4) Use of Pollution Prevention

4(5) Use of Alternatives

4(6) Keep additional documents with the plan

4(7) One year of monitoring after meeting the reduction target (before the end of the implementation period)

9.0 Certification

I hereby certify that the information provided in this Report is true, accurate and complete.

_____________________________________________________________________

Signature of the Person Subject to the Notice or Duly Authorized Representative

_____________________________________________________________________

Date

Name: ___________________________________________________________

Please Print

Title/Position: ______________________________________________________

Please Print

Schedule 5: Declaration That a Pollution Prevention Plan Has Been Implemented — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 58(2) of CEPA 1999)

Notice Reference Code: P2D4

For guidance on how to complete this Declaration, please refer to the “Instructions for Completing the Schedules — Pollution Prevention Planning Notice in respect of Cyclotetrasiloxane, octamethyl- (siloxane D4) in Industrial Effluents.” These instructions can be found on the Pollution Prevention (P2) Planning section of Environment Canada’s Web Site at www.ec.gc.ca/planp2-p2plan/default.asp?lang=En&n=51567C93-1.

Is this an amendment to a Declaration previously submitted? Yes No

If no, please proceed to Part 1.0 of this Declaration.

Amendment Part(s)

Please specify the parts of the Declaration that you would like to amend.

Amendment Reason(s)

Please specify the reasons for each of the amendments that you would like to make.

1.0 Information on the Person Subject to the Notice

Name of the Person Subject to the Notice: ___________________________________

Facility Name: _________________________________________________________

Street Address of Facility: _______________________________________________

City: _______________________________________________________________

Province/Territory: ______________________________________________________

Postal Code: __________________________________________________________

Telephone Number: ____________________________________________________
(with area code)

Email: _______________________________________________________________

Mailing Address of Facility (if different from Street Address):

____________________________________________________________________

City: _________________________________________________________________

Province/Territory: ______________________________________________________

Postal Code: ___________________________________________________________

National Pollutant Release Inventory ID (if no ID, leave blank): ___________________

Six-digit North American Industry Classification System (NAICS) Code
(if no Code, leave blank): ________________________________________________

Facility Technical Contact: ________________________________________________

Email: _______________________________________________________________

Telephone Number: ___________________________________________________
(with area code)

Fax Number (if available): _______________________________________________
(with area code)

General Contact Information

First Name: ______________________________________________________

Last Name: ______________________________________________________

Email: __________________________________________________________

Position/Job Title: ________________________________________________

Telephone Number: _______________________________________________
(with area code)

Fax Number (if available): __________________________________________
(with area code)

2.0 Use of Plans Prepared or Implemented for Another Purpose — No data is required for Part 2.0 of this Declaration

Parts 3.0 through 7.0 must be completed separately for each Activity selected in Part 3.0 below.

3.0 Substance and Activity

Substance and Activity for which information is required (choose all those that apply):

Manufacture of D4 (see footnote 4)
Use of D4 or a mixture that contains D4

4.0 Information after Implementation of the Pollution Prevention (P2) Plan

Notes:

a) Wherever possible, the data collected in Part 4.0 of this Declaration are consistent with the reporting requirements of the National Pollutant Release Inventory (NPRI).
b) In Part 4.0, where indicated, use the following Basis of Estimate Codes to describe how each quantity reported was determined:
1. M1 Continuous Emission Monitoring System
2. M2 Predictive Emission Monitoring
3. M3 Source Testing
4. C Mass Balance
5. E1 Site-specific Emission Factor
6. E2 Published Emission Factor
7. O Engineering Estimates
8. X Other (please specify) : ____________________________________
c) This Declaration requires reporting of data for the 2016 Implementation Year (June 2, 2016, to June 1, 2017) of the Pollution Prevention Plan.

If you are reporting data for a year other than the above-specified year, because either you have been granted a time extension to implement a plan or you became subject to the Notice after the date of publication, which resulted in an Implementation Year other than 2016, please indicate the new Year of Implementation for which you are reporting: _________. In addition, please provide the start and end dates representing one full year’s duration (e.g. 2015-07-23 to 2016-07-22): _____________________ to __________________________.

All references to the Implementation Year 2016 throughout the Declaration will be replaced by the new Implementation Year.

4.1 Nature of Activity and On-Site Uses/Manufacturing

For the activity identified in Part 3.0 of this Declaration, did this facility use or manufacture the substance on-site in the Year of Implementation? Yes No

If no, proceed to Part 4.3 of this Declaration.

If yes, please complete the table in Part 4.1.1 if the activity selected in Part 3.0 was “Manufacture of D4.” Please complete the tables in Part 4.1.2 (a) and (b) if the activity selected in Part 3.0 was “Use of D4 or a mixture that contains D4.” It should be noted that more than one nature of activity may be identified and at least one nature of activity must be selected.

4.1.1 Manufacture of D4

Indicate the nature of the activity in relation with the manufacture of D4 at the facility for the Implementation Year. In addition, report the total quantity of D4 manufactured during the Implementation Year, in kilograms (kg), for these natures of activities and the Basis of Estimate Code (see Part 4.0, Note b) in the appropriate fields below.

Nature of Activity	Total Quantity of D4 Manufactured (kg)	Basis of Estimate Code
For on-site use/processing
For sale/distribution
As a by-product
As an impurity
Other
Total		n/a

If “Other” is selected, please provide a description: __________________________

4.1.2 Use of D4 or a mixture that contains D4

4.1.2 (a) Nature of Activity

Indicate the nature of activity in relation with the use of D4 or a mixture that contains D4 at the facility for the Implementation Year. Also indicate the quantity (kg) of D4 used for the Implementation Year and the Basis of Estimate Code (see Part 4.0, Note b) in the appropriate fields below.

Nature of Activity	Total Quantity of D4 Used (kg)	Basis of Estimate Code
As a reactant
As a formulation component
As an article component
As a by-product
As a physical or chemical processing aid
As a manufacturing aid
For repackaging only
Other
Total		n/a

If “Other” is selected, please provide a description: __________________________

4.1.2 (b) Manufacture Product

Indicate the type of manufactured product resulting from the use of D4 or a mixture that contains D4 at the facility for the Implementation Year.

Types of Product Manufactured
Silicone polymers or copolymers
Personal care products
Adhesives or sealants
Paints or coatings
Pharmaceutical products
Soap or cleaning compounds
Other

If “Other” is selected, please provide a description: ___________________________

4.2 No data required for Part 4.2 of this Declaration

4.3 On-site Releases

For the activity identified in Part 3.0 of this Declaration, did this facility release an effluent containing D4 at any final discharge point in the Implementation Year? Yes No

If no, proceed to Part 5.0 of this Declaration. If yes, proceed to Part 4.3.3.

4.3.1 Releases to Air — No data required for Part 4.3.1 of this Declaration

4.3.2 Underground Injection — No data required for Part 4.3.2 of this Declaration

4.3.3 Releases to Water

Report below the quantity of all releases of the substance to water in kg, for that year, and the Basis of Estimate Code (see Part 4.0, Note b) in the appropriate field below.

Type of Releases	Quantity of D4 Released for the Implementation Year (kg)	Basis of Estimate Code
a) Surface water
b) Wastewater system
Total		n/a

4.3.4 Releases to Land — No data required for Part 4.3.4 of this Declaration

4.4 No data required for Part 4.4 of this Declaration

4.5 Additional Baseline Information

4.5.1 Sampling and Analysis

Please indicate the number of final discharge points for which you are reporting:

_____________________________________________________________

For each final discharge point, indicate the number of samples collected:

______________________________________________________________

Final Discharge Point 1
Sample	Location Where the Sample Was Collected (check the appropriate box)		Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
Sample	Final Discharge Point	Other Location	Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
1
2
3
4

Final Discharge Point 2
Sample	Location where the Sample Was Collected (check the appropriate box)		Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
Sample	Final Discharge Point	Other Location	Date of Sampling	Date of Analysis	Laboratory Name, City and Phone Number	Concentration of D4 in the Sample (µg/L)
1
2
3
4

If less than four samples were collected for a final discharge point, please explain why.

If the samples are collected at a location other than the final discharge point of the facility, please justify and explain the relation with the final discharge point.

4.5.2 Details on Final Discharge Point(s) of the facility

Final Discharge Point	Type of Release (check the appropriate box)		Name of the Surface Waters or WWTP	Location (address or geographical coordinates)
Final Discharge Point	Surface Water	Wastewater System	Name of the Surface Waters or WWTP	Location (address or geographical coordinates)
1
2

5.0 Actions Taken and Results Achieved

5.1 Actions Taken

Parts 5.1.1 through 5.1.6 must be completed separately for each action taken in the P2 plan, i.e. Part 5.1 will be completed as many times as there are actions taken to report.

In Part 5.1.1, describe, for the activity identified in Part 3.0 of this Declaration, the action taken in implementing the Pollution Prevention Plan. If the action taken includes the use of alternative substances, please include the chemical name, common name or CAS number of the substance. If the action taken includes the use of pollution control, please include a description of the pollution control method.

Report only those actions that have been taken since the last Interim Progress Report.

5.1.1 Action Taken

What is the current status of this Action?

Planned/To be initiated
In progress
Completed
Discontinued

If the action is “Discontinued,” please provide the reason why you will no longer be carrying out this action for the activity.

For the action taken reported above, identify whether it represents a pollution prevention method mentioned in Part 5.1.2 OR an environmental protection method mentioned in Part 5.1.3.

5.1.2 Types of Pollution Prevention Methods:

For a detailed description of pollution prevention methods, please refer to the Pollution Prevention Planning Handbook (www.ec.gc.ca/planp2-p2plan/default.asp?lang=En&n=56875F44-1).

5.1.3 Types of Environmental Protection Methods:

Select from the list of options provided below, one or more environmental protection methods to describe the action taken reported in Part 5.1.1.

Energy recovery
Off-site recycling
Incineration with energy recovery
Waste treatment
ollution control
Disposal
Other: _________________________________________

In Part 5.1.4, report, where possible, the corresponding change in annual releases of the substance achieved by implementing that action in kg and μg/L. Indicate a decrease with a negative sign (“–”) and an increase with a positive sign (“+”) in front of the reported quantity. Note that estimating a quantitative change for some actions taken, such as employee training, may not be possible.

5.1.4 Changes Achieved: _______________________________________________

In Part 5.1.5, describe which elements of the Baseline Elements identified in Part 4.0 (see below) are affected by the changes reported in 5.1.4. Note actions may affect more than one Baseline Element.

A = total quantity manufactured on-site
B = total quantity used on-site
C = total quantity released to water (surface waters or wastewater system)
D = effluent concentration at final discharge point(s)
E = other (If other is selected, please provide a short description.)

5.1.5 Baseline Elements Affected: _______________________________________

Finally, in Part 5.1.6, identify the completion date for the action taken.

5.1.6 Completion Date (YYYY-MM-DD): _____________________________________

This ends Parts 5.1.1 through 5.1.6 that must be completed separately for each action taken in the P2 plan.

5.2 No Data Required for Part 5.2 of this Declaration

5.3 Total Results Achieved

The table below summarizes, for the activity identified in Part 3.0 of this Declaration, the total change achieved in annual releases of the substance in kg, μg/L and as a percentage relative to the Preparation Year as reported in Schedule 1.

Report the total changes achieved by implementing all the actions taken as a result of implementing the Pollution Prevention Plan, as described in Part 5.1 of this Declaration.

Important: Indicate a decrease with a negative sign (“–”) and an increase with a positive sign (“+”) in front of the reported quantity.

Type of Releases	Final Discharge Point	Total Change Achieved (in concentration) Relative to the Preparation Year (μg/L)	Total Change Achieved (in concentration) Relative to the Preparation year (%)
On-site releases	1
	2
	Total	n/a	n/a

6.0 Monitoring and Reporting

Describe the monitoring and reporting used to track progress in implementing the Pollution Prevention Plan.

7.0 Risk Management Objective

Describe how the Pollution Prevention Plan met the reduction target identified in subsection 4(2) of the Notice.

If this Plan did not meet the reduction target, explain why.

This ends Parts 3.0 through 7.0 of this Declaration to be completed separately for each Activity specified in Part 3.0 above.

8.0 Factors to Consider

Describe any progress made in this Implementation Year towards taking into account the “Factors to Consider in Preparing the Plan” set out in subsections 4(3) to 4(7) of the Notice, except those factors for which a waiver has been granted by the Minister of the Environment.

4(3) Sampling and Analysis activities

4(4) Use of Pollution Prevention

4(5) Use of Alternatives

4(6) Keep additional documents with the plan

4(7) One year of monitoring after meeting the reduction target (before the end of the implementation period)

9.0 Certification

I hereby certify that a Pollution Prevention Plan has been implemented in respect of Cyclotetrasiloxane, octamethyl- (siloxane D4) in industrial effluents and that the information provided in this Declaration is true, accurate and complete.

_____________________________________________________________________

Signature of the Person Subject to the Notice or Duly Authorized Representative

_____________________________________________________________________

Date

Name: _________________________________________________________

Please Print

Title/Position: ____________________________________________________

Please Print

Footnotes

Footnote 1
The Chemical Abstracts Service (CAS) Registry Number is the property of the American Chemical Society and any use or redistribution, except as required in supporting regulatory requirements and/or for reports to the Government when the information and the reports are required by law or administrative policy, is not permitted without the prior, written permission of the American Chemical Society.

Footnote 2
D4 refers to Cyclotetrasiloxane, octamethyl- (CAS Registry Number 556-67-2).
The Chemical Abstracts Service (CAS) Registry Number is the property of the American Chemical Society and any use or redistribution, except as required in supporting regulatory requirements and/or for reports to the Government when the information and the reports are required by law or administrative policy, is not permitted without the prior, written permission of the American Chemical Society.

Footnote 3
D4 refers to Cyclotetrasiloxane, octamethyl- (CAS Registry Number 556-67-2).
The Chemical Abstracts Service (CAS) Registry Number is the property of the American Chemical Society and any use or redistribution, except as required in supporting regulatory requirements and/or for reports to the Government when the information and the reports are required by law or administrative policy, is not permitted without the prior, written permission of the American Chemical Society.

Footnote 4
D4 refers to Cyclotetrasiloxane, octamethyl- (CAS Registry Number 556-67-2).
The Chemical Abstracts Service (CAS) Registry Number is the property of the American Chemical Society and any use or redistribution, except as required in supporting regulatory requirements and/or for reports to the Government when the information and the reports are required by law or administrative policy, is not permitted without the prior, written permission of the American Chemical Society.

Canada Gazette, Part I, Volume 146, Number 22: SUPPLEMENT

DEPARTMENT OF THE ENVIRONMENT

CANADIAN ENVIRONMENTAL PROTECTION ACT, 1999

NOTICE REQUIRING THE PREPARATION AND IMPLEMENTATION OF POLLUTION PREVENTION PLANS IN RESPECT OF CYCLOTETRASILOXANE, OCTAMETHYL- (SILOXANE D4) IN INDUSTRIAL EFFLUENTS

EXPLANATORY NOTE

Schedule 1: Declaration That a Pollution Prevention Plan Has Been Prepared and Is Being Implemented — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 58(1) of CEPA 1999)

Amendment Part(s)

Amendment Reason(s)

1.0 Information on the Person Subject to the Notice

2.0 Use of Plans Prepared or Implemented for Another Purpose

3.0 Substance and Activity

4.0 Baseline Information Prior to Implementation of the Pollution Prevention (P2) Plan

4.1 Nature of Activity and On-Site Uses/Manufacturing

4.2 No data required for Part 4.2 of this Declaration

4.3 On-site Releases

4.4 No data required for Part 4.4 of this Declaration

4.5 Additional Baseline Information

5.0 Anticipated Actions and Results

5.1 Anticipated Action

5.2 No Data Required for Part 5.2 of this Declaration

5.3 Total Anticipated Results

6.0 Monitoring and Reporting

7.0 Risk Management Objective

8.0 Factors to Consider

9.0 Certification

Schedule 2: Request for Waiver of the Requirement to Consider a Factor or Factors — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 56(5) of CEPA 1999)

Amendment Part(s)

Amendment Reason(s)

1.0 Information on the Person Subject to the Notice

2.0 Factor(s) for Which a Waiver is Being Requested

3.0 Rationale for Request

4.0 Certification

Schedule 3: Request for Time Extension — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 56(3) of CEPA 1999)

Amendment Part(s)

Amendment Reason(s)

1.0 Information on the Person Subject to the Notice

2.0 Request for Time Extension

3.0 Rationale for Request

4.0 Certification

Schedule 4: Interim Progress Report — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents

Amendment Part(s)

Amendment Reason(s)

1.0 Information on the Person Subject to the Notice

2.0 Use of Plans Prepared or Implemented for Another Purpose — No data is required for Part 2.0 of this Report

3.0 Substance and Activity

4.0 Progress Information During Implementation of the Pollution Prevention (P2) Plan

4.1 Nature of Activity and On-Site Uses/Manufacturing

4.2 No data required for Part 4.2 of this Declaration

4.3 On-site Releases

4.4 No data required for Part 4.4 of this Report

4.5 Additional Progress Information

5.0 Action(s) Taken and Results Achieved to Date

5.1 Action(s) taken to date

5.2 No Data Required for Part 5.2 of this Report

5.3 Total Results Achieved To Date

6.0 Monitoring and Reporting

7.0 Risk Management Objective

8.0 Factors to Consider

9.0 Certification

Schedule 5: Declaration That a Pollution Prevention Plan Has Been Implemented — Pollution Prevention Planning Notice in Respect of Cyclotetrasiloxane, octamethyl- (Siloxane D4) in Industrial Effluents (Subsection 58(2) of CEPA 1999)

Amendment Part(s)

Amendment Reason(s)

1.0 Information on the Person Subject to the Notice

2.0 Use of Plans Prepared or Implemented for Another Purpose — No data is required for Part 2.0 of this Declaration

3.0 Substance and Activity

4.0 Information after Implementation of the Pollution Prevention (P2) Plan

4.1 Nature of Activity and On-Site Uses/Manufacturing

4.2 No data required for Part 4.2 of this Declaration

4.3 On-site Releases

4.4 No data required for Part 4.4 of this Declaration

4.5 Additional Baseline Information

5.0 Actions Taken and Results Achieved

5.1 Actions Taken

5.2 No Data Required for Part 5.2 of this Declaration

5.3 Total Results Achieved

6.0 Monitoring and Reporting

7.0 Risk Management Objective

8.0 Factors to Consider

9.0 Certification

NOTICE REQUIRING THE PREPARATION AND IMPLEMENTATION OF POLLUTION PREVENTION PLANS IN RESPECT OF CYCLOTETRASILOXANE, OCTAMETHYL-
(SILOXANE D4) IN INDUSTRIAL EFFLUENTS