Prince Edward Island-Collectors annual statement

Amongst the following products, which one(s) were you registered for as an Atlantic Used Oil Management Association (PE) collector?*

Used oilUsed glycol (antifreeze)Used filtersUsed oil, glycol (antifreeze) and diesel exhaust fluid containersUsed aerosol containers (lubricants and automotive parts cleaners only)

Used oil
Please indicate below the quantity of used oil your company had in inventory on the dates shown for the statement year. *

January 1st December 31st

Quantity (L)
Quantity of Atlantic Used Oil Management Association (PE) used oil collected in the last year (in liters) *
Total quantity of used oil collected in the last year (in liters) *

	January 1st	December 31st
Quantity (L)

Used glycol (antifreeze)
Please indicate below the quantity of used glycol (antifreeze) your company had in inventory on the dates shown for the statement year. *

January 1st December 31st

Quantity (L)
Quantity of Atlantic Used Oil Management Association (PE) used glycol (antifreeze) collected in the last year (in liters) *
Total quantity of used glycol (antifreeze) collected in the last year (in liters) *

	January 1st	December 31st
Quantity (L)

Used filters
Please indicate below the quantity of used filters your company had in inventory on the dates shown for the statement year.*

January 1st December 31st

Quantity (kg)
Quantity of Atlantic Used Oil Management Association (PE) used filters collected in the last year (in kg) *
Total quantity of used filters collected in the last year (in kg) *

	January 1st	December 31st
Quantity (kg)

Used oil, glycol (antifreeze) and diesel exhaust fluid containers
Please indicate below the quantity of used oil, glycol (antifreeze) and diesel exhaust fluid containers your company had in inventory on the dates shown for the statement year. *

January 1st December 31st

Quantity (kg)
Quantity of Atlantic Used Oil Management Association (PE) used oil, glycol (antifreeze) and diesel exhaust fluid containers collected in the last year (in kg) *
Total quantity of used oil, glycol (antifreeze) and diesel exhaust fluid containers collected in the last year (in kg) *

	January 1st	December 31st
Quantity (kg)

Used aerosol containers (lubricants and automotive parts cleaners only)
Please indicate below the quantity of used aerosol containers (lubricants and automotive parts cleaners only) your company had in inventory on the dates shown for the statement year.*

January 1st December 31st

Quantity (kg)
Quantity of Atlantic Used Oil Management Association (PE) used aerosol containers (lubricants and automotive parts cleaners only) collected in the last year (in kg) *
Total quantity of used aerosol containers (lubricants and automotive parts cleaners only) collected in the last year (in kg) *

	January 1st	December 31st
Quantity (kg)

Signatory name*
Signatory title*
Email address*
I, {signatoryName}, {signatoryTitle} confirm the information provided on this form is accurate and I recognize it could be subject to audits. The detailed files supporting this claim are available for consultation upon request.
Signature*

Clear
I confirm my signature
Date*

MonthDayYear
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