DEREGISTRATION FORM AS A PRODUCER OF BATTERIES AND ACCUMULATORS FORM F YEAR 2017 Your application shall be accompanied by: All pending reporting information until the date indicated in Section 2; A signed agreement between interested parties only in the case of transfer of a producer s business to another; A copy of a signed declaration by the Waste Batteries & Accumulators Compliance Scheme indicating that you are no longer a member of the said Scheme, if applicable. Should you require assistance in completing your deregistration form please contact us on: Phone: 2292 3500 Email: epr.permitting@era.org.mt 1. Details of Company/Producer [Please complete in BLOCK letters] Producer Registration Number WMB/ / FULL Name of Company/Producer [As appearing on the public register] Company Registration Number [if applicable]: VAT Number: Are you a member of an authorised Waste Batteries & Accumulators Compliance Scheme? If Yes, please provide: Name of the Waste Batteries & Accumulators Compliance Scheme Scheme s membership number Yes No 2. Reason for Deregistration [Please tick one of the following to indicate your reason for deregistration] I have ceased placing batteries & accumulators on the market as from I have ceased trading as from Company has run into liquidation as from I have closed down the business as from I have transferred the business* as from [*You are kindly requested to endorse a signed agreement between both parties, proving to the Competent Authority that the person to whom the transfer of business has been made has agreed to meet the producer s obligations under the Waste Batteries & Accumulators Regulations (SL 549.54)] Page 1
3. Batteries and Accumulators placed on the national market [Please indicate quantity, by weight of batteries & accumulators placed on the market in 2016] PORTABLE BATTERIES & ACCUMULATORS (PRIMARY/NON-RECHARGEABLE) weight (kg) Button Cells PORTABLE BATTERIES & ACCUMULATORS (SECONDARY/RECHARGEABLE) weight (kg) AUTOMOTIVE BATTERIES & ACCUMULATORS weight (kg) INDUSTRIAL BATTERIES & ACCUMULATORS weight (kg) Alkaline Page 2
4. Waste Batteries & Accumulators Collected [Please indicate quantity, by weight of waste batteries & accumulators collected in 2016] PORTABLE WASTE BATTERIES & ACCUMULATORS (PRIMARY/NON-RECHARGEABLE) weight (kg) Button Cells PORTABLE WASTE BATTERIES & ACCUMULATORS (SECONDARY/RECHARGEABLE) weight (kg) AUTOMOTIVE WASTE BATTERIES & ACCUMULATORS weight (kg) INDUSTRIAL WASTE BATTERIES & ACCUMULATORS weight (kg) Alkaline Page 3
5. Waste Batteries & Accumulators Treated [Please indicate quantity, by weight waste batteries & accumulators treated in 2016] PORTABLE WASTE BATTERIES & ACCUMULATORS (PRIMARY/NON-RECHARGEABLE) weight (kg) Button Cells PORTABLE WASTE BATTERIES & ACCUMULATORS (SECONDARY/RECHARGEABLE) weight (kg) AUTOMOTIVE WASTE BATTERIES & ACCUMULATORS weight (kg) INDUSTRIAL WASTE BATTERIES & ACCUMULATORS weight (kg) Alkaline If not a member of a waste batteries and accumulators compliance scheme, please submit a signed declaration from an authorised waste management undertaking/establishment that the waste batteries and accumulators have been recovered/recycled in an environmentally sound manner. Page 4
6. Recycling Efficiencies Were the recycling efficiencies laid down in S.L. 549.54 achieved? Yes No The producer must submit a signed declaration issued by the person exporting the waste batteries and accumulators on his/her behalf, including the following information: - Details of the person exporting the waste batteries & accumulators; - A declaration on whether the recycling efficiencies for the exported waste batteries & accumulators have been met, including the rate (%) achieved by the facility overseas; - The permit number under which the waste batteries & accumulators were exported; - The country of export and the name of the facility overseas. Declaration Statement By signing this form, you confirm that you are giving your explicit consent, in terms of the Data Protection Act, on behalf of yourself and all the other persons specified in this form for the Authority to process your respective personal information. It is an offence if you deliberately give false or misleading information. You may be liable to prosecution. The application must be signed and submitted to the Authority by an Authorised Signatory. I declare that the information in this form is true to the best of my knowledge and belief. I understand that deregistration may be refused if I give false or incomplete information. I confirm that I would like to deregister as a producer of batteries and accumulators pursuant to regulation 17(3) of S.L. 549.54 the Waste Management (Waste Batteries and Accumulators) Regulations. I declare that should I recommence placing batteries and accumulators on the market, I shall apply for registration as a producer of batteries and accumulators with the Competent Authority pursuant to regulation 17(1) of S.L. 549.54 the Waste Management (Waste Batteries and Accumulators) Regulations. Name & Surname Signature of Applicant Date (DD/MM/YYYY) Complete forms are to be handed in or sent by post to: Environment & Resources Authority, Hexagon House, Spencer Hill, Marsa, MRS 1441 For Office Use Only Date Stamp Producer Registration Number Accepted Refused Page 5
DATA PROTECTION ACT, 2001 The Environment & Resources Authority will process any personal and/or sensitive data supplied in this application for all or any of the following: 1. Preventing, detecting and/or prosecuting fraud and any other criminal activity which the Authority is bound to report and/or act upon whilst meeting any other specific legal or regulatory obligations; 2. Establishing, exercising or defending any legal action; 3. Internal management, research and statistics, systems administration, the development and improvement of our services; 4. The protection and promotion of our legitimate interests and the proper conduct of our obligations arising under any law or statutory instrument; and 5. To make public the necessary information as specified in the relevant law and/or instrument. Relevant data will be disclosed or shared as appropriate with all our employees and with other third parties if pertinent to any of the purposes listed above. Page 6