Quebec-Collectors annual statement

SOGHU - Collectors annual statement
Statement for the year
SOGHU #*
Company legal name*
Address*

Street Address

Street Address (line 2)

MunicipalityProvince/State

Postal/Zip Code
Telephone*

Area CodePhone #
Extension

Amongst the following products, which one(s) were you registered for as a SOGHU collector?*

Used oilUsed glycol (antifreeze)Used filtersUsed oil and glycol (antifreeze) containersUsed aerosol containers (lubricants and brake 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 SOGHU used oils collected over the last year (in liters). *
Total quantity of used oils collected over the last year (in liters). *

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 SOGHU used glycol (antifreeze) collected over the last year (in liters). *
Total quantity of used glycol (antifreeze) collected over the last year (in liters). *

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 SOGHU used filters collected over the last year (in kg). *
Total quantity of used filters collected over the last year (in kg).*

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

January 1st December 31st

Quantity (kg)
Quantity of SOGHU used oil and glycol (antifreeze) containers collected over the last year (in kg). *
Total quantity of used oil and glycol (antifreeze) containers collected over the last year (in kg). *

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

January 1st December 31st

Quantity (kg)
Quantity of SOGHU used aerosol containers collected over the last year (in kg). *
Total quantity of used aerosol containers collected over the last year (in 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
Should be Empty: