Companies that do not meet the requirements of the Notice* are encouraged complete this form and return the signed document to the address indicated at the bottom of this page. Companies who are non-engaged, but who have a business interest in a substance identified in Batch 1 or any substance in the "Challenge" are encouraged to identify themselves as stakeholders by completing the stakeholder section below.

*Note: Requirements of the Notice are outlined in Schedule 2 to the Notice with respect to certain substances identified in the Challenge, published in the December 9, 2006 Notice of intent to develop and implement measures to assess and manage the risks posed by certain substances to the health of Canadians and their environment, published in Canada Gazette, Part I, on February 3, 2007.

IDENTIFICATION

(If your company received a letter announcing the "Challenge" program, please attach a copy of the letter.)

___ Please replace or update the identification information indicated on the letter received at our name.

___ Please add this identification information as a new company, location and contact to the "Challenge" database.

___ Please remove us from the "Challenge" database because our company does not manufacture or import any substances or products, or our company is no longer in business.

Name of the company : __________________________________________________________________

Canadian head office address: __________________________________________________________

______________________________________________________________________

Contact name for CEPA 1999 section 71 notices: _________________________________________

Title of contact: ______________________________________________________________________

Contact's address (if different from above): ___________________________________________

______________________________________________________________________

Telephone number: ________________________________ Fax machine number: _________________

Email address: ______________________________________________________________________

STAKEHOLDER IDENTIFICATION

___Please retain our name on a list of stakeholders for the following substances (If space is insufficient, please attach a typed list).

CAS Registry Number(s) and Substance Name(s): _____________________________________________

__________________________________________________________________

NON-ENGAGEMENT DECLARATION

This company was not engaged in the activities described in the Notice with respect to certain substances identified in the Challenge, published in the December 9, 2006 Notice of intent to develop and implement measures to assess and manage the risks posed by certain substances to the health of Canadians and their environment that was published in the Canada Gazette, Part I, on February 3, 2007.

Name (print)___________________________

Title__________________________________

Signature______________________________

Date of Signature______________________

Please return this form no later than June 5, 2007 to:

Minister of the Environment
To the attention of the DSL Surveys Coordinator
Place Vincent Massey, 20th Floor
351 St. Joseph Boulevard
Gatineau, Quebec K1A 0H3

Telephone: 1-888-228-0530/819-956-9313
Fax machine: 1-800-410-4314/819-953-4936
E-mail: DSL.SurveyCo@ec.gc.ca

Disclaimer: Although care has been taken to ensure that the information found on this website accurately reflects the requirements prescribed in the Canadian Environmental Protection Act (1999), you are advised that, should any inconsistencies be found, the legal documents, printed in the Canada Gazette, will prevail.