1. Name of producer or importer

2. Civic address (and mailing address if different) of producer or importer

3. Registration number(s), if any were provided by the Minister under section 7 of the Benzene in Gasoline Regulations

4. Indicate if one or more of the following apply:

• (a) producer in Canada of diesel fuel, excluding biomass-based diesel fuel and blends of biomass-based diesel fuel and diesel fuel, for

  [ ] use in on-road vehicles

  [ ] use in off-road engines

  [ ] use in vessel engines other than those installed on a vessel propelled by a large diesel engine

  [ ] use in vessel engines installed on a vessel propelled by a large diesel engine

  [ ] use in small stationary engines

  [ ] use in large stationary engines

  [ ] use in locomotive engines

  [ ] use in scientific research

  [ ] any other use (specify)

• (b) importer of diesel fuel, excluding biomass-based diesel fuel and blends of biomass-based diesel fuel and diesel fuel, for

  [ ] use in on-road vehicles

  [ ] use in off-road engines

  [ ] use in vessel engines other than those installed on a vessel propelled by a large diesel engine

  [ ] use in vessel engines installed on a vessel propelled by a large diesel engine

  [ ] use in small stationary engines

  [ ] use in large stationary engines

  [ ] use in locomotive engines

  [ ] use in scientific research

  [ ] any other use (specify)

• (c) producer in Canada of biomass-based diesel fuel for

  [ ] use in on-road vehicles

  [ ] use in off-road engines

  [ ] use in vessel engines other than those installed on a vessel propelled by a large diesel engine

  [ ] use in vessel engines installed on a vessel propelled by a large diesel engine

  [ ] use in small stationary engines

  [ ] use in large stationary engines

  [ ] use in locomotive engines

  [ ] use in scientific research

  [ ] any other use (specify)

• (d) importer of biomass-based diesel fuel for

  [ ] use in on-road vehicles

  [ ] use in off-road engines

  [ ] use in vessel engines other than those installed on a vessel propelled by a large diesel engine

  [ ] use in vessel engines installed on a vessel propelled by a large diesel engine

  [ ] use in small stationary engines

  [ ] use in large stationary engines

  [ ] use in locomotive engines

  [ ] use in scientific research

  [ ] any other use (specify)

• (e) importer of a blend of biomass-based diesel fuel and diesel fuel for

  [ ] use in on-road vehicles

  [ ] use in off-road engines

  [ ] use in vessel engines other than those installed on a vessel propelled by a large diesel engine

  [ ] use in vessel engines installed on a vessel propelled by a large diesel engine

  [ ] use in small stationary engines

  [ ] use in large stationary engines

  [ ] use in locomotive engines

  [ ] use in scientific research

  [ ] any other use (specify)

5. For each facility in Canada at which diesel fuel is produced

(a) indicate the name and civic address (and mailing address if different) of the facility

• (b) indicate the typical annual volume in m³ of diesel fuel produced for each intended use, according to fuel type, in the following table:

  	Column 1	Column 2	Column 3
  Item	Intended Use	Diesel Fuel Excluding Biomass-based Diesel Fuel and Blends of Biomass-based Diesel Fuel and Diesel Fuel	Biomass-based Diesel Fuel
  1.	Use in on-road vehicles
  2.	Use in off-road engines
  3.	Use in vessel engines other than those installed on a vessel propelled by a large diesel engine
  4.	Use in vessel engines installed on a vessel propelled by a large diesel engine
  5.	Use in small stationary engines
  6.	Use in large stationary engines
  7.	Use in locomotive engines
  8.	Use in scientific research
  9.	Any other use (specify)

6. For importers

(a) indicate the civic address (and mailing address if different) of the principal place of business in Canada

(b) indicate each usual point of entry into Canada, the province in which the point of entry is located, and the usual mode of importation for the point of entry (e.g. vessel, rail, truck, pipeline)

• (c) indicate, for each usual point of entry into Canada, the typical annual volume in m³ of diesel fuel imported for each intended use, according to fuel type, in the following table:

  	Column 1	Column 2	Column 3	Column 4
  Item	Intended Use	Diesel Fuel Excluding Biomass-based Diesel Fuel and Blends of Biomass-based Diesel Fuel and Diesel Fuel	Biomass-based Diesel Fuel	Blends of Biomass-based Diesel Fuel and Diesel Fuel
  1.	Use in on-road vehicles
  2.	Use in off-road engines
  3.	Use in vessel engines other than those installed on a vessel propelled by a large diesel engine
  4.	Use in vessel engines installed on a vessel propelled by a large diesel engine
  5.	Use in small stationary engines
  6.	Use in large stationary engines
  7.	Use in locomotive engines
  8.	Use in scientific research
  9.	Any other use (specify)

7. Authorized official

Name

Title

Signature and date

Telephone number ()

Fax number ()