Ministry of                                                       MOE*LIMS Drinking Water Sample Submission 
                                                    the Environment                                                   and Chain of Custody for Confirmation of a 
                                                                                                                      Screening Analysis
                                                                                                                       Safe Drinking Water Act 2002
        Please print or type clearly in blue or black ink only. Shaded areas for Laboratory use only. 
        Submission Information
        Submission ID                       Is this a new submission?                                  Are these samples from a drinking water system under:
                                                  Yes           No                                                                                                                                 Page 1 
                                                                                                             O.Reg 170/03                       O.Reg 318/08
                                            Add samples to submission ID:                                    O.Reg 319/08                       Not a regulated sample                             Priority
                                                                                                                                                                                                   PR
        Client ID                  Program Code                                              Date Submitted                      Time Submitted                      Original Chain-of-Custody Attached
                                   Program ID           Study ID           Project ID        (yyyy/mm/dd)                        (HR:MIN)                                 Yes           No
                                   13                   007                07                                                             :       
        Water System Legal Name                                                                        Water System Number
                                                                                                                
        Water System Owner                                                               Water System Operator                                                 Water System Operator Telephone No.
                                                                                                                                                                        
        Water System Local Medical Officer of Health                                                   Local Medical Officer of Health Tel. No.
                                                                                                                
        Water System                                                                                   Water System Location
              Source Water                   Surface                  Ground                                    
        Laboratory Contact (Last Name, First Name)                                                     Laboratory Name                                                                AWQI No.
                                                                                                                                                                                               
        Laboratory Address
        Unit No.               Street No.              Street Name                                                                  City/Town
                                                                                                                                             
        Province               Postal Code                         Telephone No. (incl. area code)                                  Fax No.
                                                                                                                                             
        Submitted by (Last Name, First Name)                                                                                        Signature
                                                                                                                                    X
        Received by (Last Name, First Name)                                                            Signature                                            Date (yyyy/mm/dd)                 Time (HR:MIN)
                                                                                                        X                                                                                               :
        Potential Hazardous Sample Information (to be completed if there is a suspected potential hazard associated with the Submission)
                                                       Potentially Hazardous Sample Information
        WHMIS Safety Data                                       
        Health                                         Field Sample ID(s)                                                                            Sample Source
                                                                                                                                                              
        Flammability                                   Laboratory Member Contacted                                                                   Potential Hazard
                                                                                                                                                              
        Reactivity                                     Field Precautions
                                                                
        Protection                                     Comments
                                                                
        Request for Analysis
        Matrix                      Field Sample ID                                                               Sample No.                                        MOE*LIMS ID
        WD                                   
        Containers Sent             Containers Missing              Sample Date             Sample Time           ELISA Result Reported to SAC                     Free Cl2                    Total Cl2
                                                                                                   :                                                                                                    
        Sample Location Description, Water System Number                                                          Sample Description (raw, treated, distribution)
                                                                                                                           
        UTM Zone                    UTM Easting                     UTM Northing                   UTM Collection Method                                UTM Map Datum UTM Accuracy (metres)
                                                                                                                                                                                               
        Is this water for human consumption as sampled?                                                           Product
             Yes           No                                                                                     MCYST3450
      2054 (2010/07)      © Queen's Printer for Ontario, 2010                                              Page 1of 2                                                                         (Instructions on reverse)
                                                                                       Guidelines for Completing Drinking Water 
                                                                                       Sample Submission and Chain of Custody for 
                                                                                       Confirmation of a Screening Analysis Form
      Submission Form
      • Form must be filled out to ensure timely processing by the Laboratory Information Management System (LIMS). 
      • Results automatically sent only to clients registered for your Client ID / Program Code. Submitter is responsible for distribution of copies.
      • If shipping samples to the laboratory, clearly show submission priority on shipping container.
                                                                                                                 Request for Analysis
      Are these samples from an O.Reg 170/03 or O.Reg 319/08 or O.Reg                  Matrix
      318/08 Drinking Water System, or unregulated system?*(Required)                  WD (Drinking Water)
      New Submission                                                                   Field Duplicate
      Indicate new Submission ID or record previous Submission ID if adding            Indicate if sample is duplicate of another in this submission. (Duplicate = 2nd 
      samples to a current submission.                                                 sample from location for identical analysis)
      Submission ID                                                                    Field Sample ID*(Required)
      Leave Blank. Created by LIMS at Sample Reception. All other entries can not      Name or identifier given sample or duplicated sample.
      be entered into LIMS.                                                            Containers Sent
      Client ID*(Required)                                                             Number of containers of this matrix and location.
      5 digit number. Submission can not be processed without a valid Client ID.       Sample Date / Time*(Required)
      Program Code*(Required)                                                          Date must be in YYYY MM DD format.  Use 24 hour clock.
      13 007 07                                                                        ELISA Result Reported to SAC*(Required)
      Priority                                                                         Include result from ELISA screening that was reported to SAC as an AWQI. 
        PR  (Priority Rush - 7 day turnaround                                          LaSB will not analyze samples below the ODWQS.
      Date Submitted*(Required)                                                        Free Cl2 and Total Cl2 *(Required for O.Reg.170/03 only)
      Date must be in YYYY MM DD format.                                               Enter the results of field testing to the appropriate column.
      Original Chain-of-Custody Attached*(Required)                                    Sample Location Description/Water System Number*(Required) 
      Select Yes or No                                                                 Enter the sample location and any additional location description: upstream, 
      Laboratory Contact*(Required)                                                    downstream, outfall etc.
      Contact name, laboratory name. Also include telephone and fax number and         Is this water for human consumption as sampled?*(Required) 
      full address details.                                                            Select Yes or No
      AWQI No.*(Required)                                                              UTM Zone*(Optional)
      Include AWQI number provided by SAC. LaSB will NOT receive the sample(s)         The Ontario Geographical Referencing System divides Ontario into four 
      without this number.                                                             zones: 15, 16, 17 or 18.
      Submitted by (signature)*(Required)                                              Easting*(Optional)
      The submission form must be signed.                                              The east-west component of a UTM coordinate. It should be six digits 
      Water System Local Medical Officer of Health*(Required for                       (+ decimal places, if any)
      regulation samples)                                                              Northing*(Optional)
                                                                                       The north-south component of an UTM coordinate. In Ontario, this may range
      WHMIS Safety Data                                                                from 4614583.73-6302884.09 metres.
      Complete if known, leave blank if unknown. Provide details for the most 
      hazardous sample.                                                                Collection Method*(Optional)
                                                                                       GPS unit or other method of location data collection
      Water System Legal Name*(Required for regulation samples)
      Available from DWIS                                                              Map Datum*(Optional)
      WaterSystem Number*(Required for regulation samples)                             NAD27 or NAD83
      WaterSystem Owner*(Required for regulation samples)                              Accuracy*(Optional)
                                                                                       The accuracy of the sample location
      WaterSystem Operator*(Required for regulation samples)
                                                                                       Sample Description*(Required)
      Water System Location*(Required)                                                 Indicate if sample is a Raw, Treated or Distribution sample, Cl2 residual
      Legal address of water system
                                                                                       Parent Product
                                                                                       Not applicable
                                                                                       Product
                                                                                       MCYST3450
                                                                                       Note: Results automatically sent only to clients registered for your Client ID / 
                                                                                       Program Code. Submitter is responsible for distribution of copies.
      Completed forms must be sent to:
      Laboratory Services Branch                                                       Customer Service Inquiries: 416 235-6030 
      125 Resources Road                                                               Customer Service Fax: 416 235-6141 
      Etobicoke ON M9P 3V6                                                             Priority Sample Requests: 416 235-6075
     2054 (2010/07)                                                              Page 2 of 2