Registration Form for the Code of Practice for the Slaughter and

Environmental Management Branch
PO Box 9377 Stn Prov Govt
Victoria, BC V8W 9M1
Fax: (250) 356-0299
Courier delivery address: 3rd Floor, 2975 Jutland Rd., Victoria BC V8T 5J9
Registration Form for the Code of Practice for the
Slaughter and Poultry Processing Industries
Please submit this completed registration form and annual fee to the Ministry of Environment by fax, registered mail or courier to the above number or
address. Additional information as per Section 4(2) of the Waste Discharge Regulation may be required by the director before the registration is effective.
Report Type - Indicate one choice (a, b or c)
To update information from a previous registration a person must re-submit a registration form with all information within 30 days
of the changes to the previous registration information. See (b) below.
To cancel a registration a person must notify a director in writing within 30 days of ceasing operations. See (c) below.
To cancel an existing authorization (e.g., permit), please contact MOE Regional Office
(a)
Initial registration
Please list any other authorizations (e.g., permit, approval, etc.) that you currently hold for discharges at this facility.
Authorization Number
Authorizing Ministry
Description (what for)
(b)
Update registration
Registration #: RE
(c)
De-register
Registration #: RE
Authorization to discharge is contingent on full compliance with the Waste Discharge Regulation and Code of Practice, including registration.
Registration will be effective 45 days after the date the completed registration form and fee are delivered to a director, unless otherwise informed.
Please complete the Applicant Information section. If you are an authorized agent or representative for the Applicant, also fill
out the Authorized Agent Information section following.
Applicant Information
(Enter a Registered Company name, OR a person's first and last name, but not both)
Company Legal Name
Doing Business As (if applicable)
or
Last Name
First Name
and
Contact Numbers
[e.g., (604) 111-2222]
Phone:
Cell:
Fax:
E-mail Address
Legal Address (as registered with B.C. Registrar
of Companies)
Mailing Address (if different from above)
Billing Address (if different from above)
Nearest Municipality to the Facility/Site
Contact Information for Operator or Facility Manager (if different from owner above)
Contact Last Name
Contact First Name
Contact Numbers
[e.g., (604) 111-2222]
Phone:
Cell:
Fax:
E-mail Address
Revision Date: June 20, 2011
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Registration Form for the Code of Practice for the Slaughter and Poultry Processing Industries
Authorized Agent Information (to be completed if representing the owner)
Agent's Company Legal Name
Doing Business As (if applicable)
Agent's Last Name
Agent's First Name
Contact Numbers
Phone:
[e.g., (604) 111-2222]
Cell:
Fax:
E-mail address
Applicant's Authorization for Agent
You need to sign this only if you are authorizing an agent or representative to deal directly with the Ministry on your behalf.
I / we (discharger) hereby authorize
to deal with the Ministry directly
(Agent)
on all aspects of this application.
Print Name of Applicant
Date (mm.dd.yyyy)
Signature of Applicant (not Agent or Representative)
Facility Information
(check the box that applies)
NAICS Code
Type of Facility:
Location:
Slaughtering poultry
311615
Slaughtering livestock (red meat)
311611
Latitude
Source
of data:
Longitude
(Must be in decimal degrees format)
GPS
or Survey
Please fill in either:
Legal Land Description
( Lot/Block/Plan )
or
PID/PIN/Crown File No.
and
Facility Address
( physical address)
Is Applicant Legal Land Owner
YES
NO
(If NO, please provide details below:)
Legal Land Owner Name
Contact Numbers
[e.g., (604) 111-2222]
Phone:
Cell:
Fax:
E-mail address
Revision Date: June 20, 2011
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Registration Form for the Code of Practice for the Slaughter and Poultry Processing Industries
Code Specific Requirements
Annual Production:
tonnes live weight killed (per calendar year).
Maximum wastewater discharge:
cubic meters per day.
Discharge Information
Description of Discharge Source:
Discharge Type:
Red Meat wastes
Refuse (Solids and semi-solids)
Liquid (wastewater)
Subsurface Discharge
Proposed Treatment
and Disposal:
Air Emissions
Landfill
(e.g., tile/drain field)
(Select all that apply)
Poultry processing wastes
Spray Irrigation
Incineration
Composting
Other:
Quantity:
Please indicate
In tonnes per year
Land Discharge by a
farmer (per s. 8(5))
Other:
Please indicate
Other:
Please indicate
Discharge Location:
(if different from facility location)
Latitude
Source GPS
of data:
Longitude
(Must be in decimal degrees format)
or Survey
Please fill in either:
Legal Land Description
( Lot/Block/Plan )
or
PID/PIN/Crown File No.
Please indicate which of the required plans are completed, and available if requested:
(The discharger must make all records available for inspection by an officer or director and must provide a copy on request within 2 business days.)
Nutrient management plan:
- For wastewater
Yes
No
Not applicable
- For land application of compost product
Yes
No
Not applicable
Landfill groundwater monitoring & assessment plan:
Yes
No
Not applicable
Landfill vector control plan:
Yes
No
Not applicable
Landfill closure plan:
Yes
No
Not applicable
Annual Fee Calculation
Annual Fee = $100.00 per media [media = air emission, effluent (liquid waste), refuse (solid and semi-solid wastes)]
Check all that apply
Cost ($100.00 each)
Media
Air Emission
Effluent
Refuse
Total annual fee =
DECLARATION
By submitting this registration form, I declare that the information contained on this form is complete and accurate information.
Name:
Signature
Date: (mmddyyyy)
Phone Number:
Revision Date: June 20, 2011
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Payment Form
Amount of Payment Submitted
Form of Payment
The Ministry of Environment accepts AMERICAN EXPRESS, MASTERCARD or VISA as well as cheque or money order. Please indicate how
you will be paying:
Cheque
Money Order
Credit Card (Please provide your credit card information in the area below)
Cheque or Money Order Payment Option
For payment by cheque or money order please make payable to Minister of Finance and mail to the appropriate address below.
Name as it appears on cheque or money order:
Credit Card Payment Option
Do not complete this section if you are paying by cheque or money order.
Please bill my:
AMERICAN EXPRESS
MASTERCARD
VISA
Name as it appears on Credit Card
Name of applicant if different than name on Card
Contact telephone number for Card Holder
Credit Card Number
Credit Card Expiry Date
Signature
Credit card information provided on this form will not be retained. Upon authorization of payment request, this page will be destroyed.
Mailing and Contact Information
You can MAIL your completed application form with a cheque, money order or this credit card payment form to:
Environmental Management Branch
Ministry Of Environment
PO Box 9377 Stn Prov Govt
Victoria, BC V8W 9M1
Or DELIVER by courier to:
rd
3 Floor, 2975 Jutland Road, Victoria, BC V8T 5J9
You can FAX your completed application form and this credit card payment form to: (250) 356-0299
Revision Date: June 20, 2011
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