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Grow Operations and/or Mould Reporting Forms
Please submit with the full report
Registered Property Owner
Name
Telephone
Address the report pertains to:
Street
City
To be completed by the Reporting Agency:
Company / Agency submitting the attached report:
Name:
Declaration
I,
,(full name), do solemnly declare that I have the knowledge, experience and training to
design a testing plan and analyze results. All the criteria as set forth in this document have been
met. To the best of my knowledge and belief after having made the necessary inquiries, tests and/or
inspections, the premises does not pose a risk of biological or chemical hazard to an individual
entering the premises, and is safe to enter for inspection.
Name (please print)
Title
Phone
Email
Signature
Professional Designation
CIH
ROH
ROHT
CRSP
P.Eng
**Must have one of the above designations; please specify
ESA Reserves the right to decline reports that do not meet all the criteria requirements and/or any
reports that exceed 90 days since testing and completion.
ESA requires a professional report declaring the property is safe for entry in order to conduct an
inspection at a site that has actual or potential unsafe air quality or hygiene. If a space must be
entered for inspection then testing is required, this includes; attics, barns, crawlspaces, and sheds.
HS-3011
Revision level: 2
Revision date: January 2014
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Grow Operations and/or Mould Reporting Forms
I, as the representative of the company providing the declaration confirm that all of the following
are included in the full report:
Yes
A description of the facility and where the chemical and/or biological hazard was found.
The standards or test methods used for comparison (e.g. as applicable: American
Conference of Governmental Industrial Hygienists (ACGIH), Health Canada Guidelines,
National Institute for Occupational Safety and Health (NIOSH), Occupational Exposure
Limits (OEL’s)).
The name and accreditation of the laboratory performing the analysis:
 Must be an American Industrial Hygiene Association (AIHA) accredited
laboratory -Environmental Microbiology Laboratory Accreditation Program
(EMLAP) or equivalent.
 http://www.aihaaccreditedlabs.org/Pages/ListofAccreditedLabs.aspx
The method of sampling and analysis including description of sampling equipment,
description of conditions under which sampling was undertaken, number of blanks (if
required), and findings.
Quality control measures (calibration, chain of custody);
Conclusion of the tests and Recommendations;
The owner or agency representing the owner has indicated that no structural changes have
occurred.
Notes:
 When the facility/property had been structurally altered, a signed statement from a
Professional Engineer, complete with Professional Engineering stamp, declaring the facility
is structurally sound and is safe to enter is required.
 The company performing the declaration must be independent from the company
performing the remedial work (clean up).
 This form, and relevant sections, are to be used for grow house operations, meth lab
operations, and general mould concerns.
Submit forms with full report to:
Electrical Safety Authority
E-mail:hygiene.reports@electricalsafety.on.ca
Fax: 905-712-7845
Mailing Address: 155A Matheson Blvd West, Mississauga Ontario L5R 3L5
HS-3011
Revision level: 2
Revision date: January 2014