This form provides the information to fulfil Canada's obligation under Article V of the Canada/U.S. Air Quality Agreement. The form needs to be completed for any NEW air pollution source located within 100 km of the Canada/U.S. border that is expected to emit greater than 90 tonnes per year of any one of the common air pollutants: sulphur dioxide (SO2), nitrogen oxides (NOx), carbon monoxide (CO), total suspended particulates (TSP) and volatile organic compounds (VOC), where VOCs are defined as compounds containing at least one carbon atom, excluding carbon monoxide, carbon dioxide, methane and chlorofluorocarbons. Notification is also required for major modifications of existing facilities which would result in an increase of 40 or more tonnes per year of one or more common pollutants. With respect to hazardous air pollutants, Notification is required if a new source, or a modification of an existing source, results in a release of greater than 1 tonne per year of any one hazardous air pollutant. For the purposes of Notification, a hazardous air pollutant is any substance in the National Pollutant Release Inventory.

If the proposed facility does not meet the Notification criteria, there is no requirement to complete and return the form to Environment Canada.

Date Submitted: ____________________

Name and full address of proponent including a contact for technical information:

Contact phone: ( ) ____ - _____
Fax: ( ) ____ - _____

Brief description of the proposed project. (major products, process, capacity, etc):

Latitude and Longitude of proposed facility:

_______________'N _______________'W

Distance to the Canada/U.S. border (to the nearest kilometre):

__________ km

For combustion processes, list capacity (tonnes/year), fuel type and grade.

Capacity: _______________ tonnes/year
Fuel Type: _______________
Fuel Grade: _______________

What are the estimated annual quantities of the following pollutants released to the atmosphere (tonnes per year)?

SO2 _______________ tonnes/year
PM _______________ tonnes/year
VOCs _______________ tonnes/year
CO _______________ tonnes/year
NOx _______________ tonnes/year
(equivalent to NO2)

List hazardous air pollutants with emissions estimate (tonnes/year) for any hazardous pollutants with expected annual emission rates of greater than 1 tonne per year:

Forward completed forms to:

Transboundary Air Issues Branch
Environmental Protection Service
Environment Canada
Ottawa, Ontario
K1A 0H3