MOE*LIMS Drinking Water Sample Submission
and Chain of Custody for Confirmation of a
Screening Analysis
Ministry of
the Environment
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?
Yes
No
Add samples to submission ID:
Client ID
Program Code
Program ID Study ID
Project ID
13
07
007
Are these samples from a drinking water system under:
O.Reg 170/03
O.Reg 318/08
O.Reg 319/08
Not a regulated sample
Date Submitted
(yyyy/mm/dd)
Time Submitted
(HR:MIN)
PR
Original Chain-of-Custody Attached
Yes
No
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
Source Water
Water System Location
Surface
Ground
Laboratory Contact (Last Name, First Name)
Province
Priority
:
Water System Legal Name
Laboratory Address
Unit No.
Street No.
Page 1
Laboratory Name
Street Name
Postal Code
AWQI No.
City/Town
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)
X
Time (HR:MIN)
:
Potential Hazardous Sample Information (to be completed if there is a suspected potential hazard associated with the Submission)
WHMIS Safety Data
Potentially Hazardous Sample Information
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
ELISA Result Reported to SAC
Free Cl2
WD
Containers Sent
Containers Missing
Sample Date
Sample Time
Total Cl2
:
Sample Location Description, Water System Number
UTM Zone
UTM Easting
UTM Northing
Is this water for human consumption as sampled?
Yes
No
2054 (2010/07)
© Queen's Printer for Ontario, 2010
Sample Description (raw, treated, distribution)
UTM Collection Method
UTM Map Datum
UTM Accuracy (metres)
Product
MCYST3450
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(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
318/08 Drinking Water System, or unregulated system?*(Required)
Matrix
New Submission
Field Duplicate
Indicate new Submission ID or record previous Submission ID if adding
samples to a current submission.
Indicate if sample is duplicate of another in this submission. (Duplicate = 2nd
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
be entered into LIMS.
Name or identifier given sample or duplicated sample.
Client ID*(Required)
Number of containers of this matrix and location.
WD (Drinking Water)
5 digit number. Submission can not be processed without a valid Client ID.
Containers Sent
Sample Date / Time*(Required)
Date must be in YYYY MM DD format. Use 24 hour clock.
Program Code*(Required)
13 007 07
ELISA Result Reported to SAC*(Required)
Include result from ELISA screening that was reported to SAC as an AWQI.
LaSB will not analyze samples below the ODWQS.
Priority
PR (Priority Rush - 7 day turnaround
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,
downstream, outfall etc.
Laboratory Contact*(Required)
Contact name, laboratory name. Also include telephone and fax number and
full address details.
Is this water for human consumption as sampled?*(Required)
AWQI No.*(Required)
UTM Zone*(Optional)
Include AWQI number provided by SAC. LaSB will NOT receive the sample(s)
without this number.
The Ontario Geographical Referencing System divides Ontario into four
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
(+ decimal places, if any)
Water System Local Medical Officer of Health*(Required for
regulation samples)
WHMIS Safety Data
Complete if known, leave blank if unknown. Provide details for the most
hazardous sample.
Water System Legal Name*(Required for regulation samples)
Available from DWIS
WaterSystem Number*(Required for regulation samples)
WaterSystem Owner*(Required for regulation samples)
WaterSystem Operator*(Required for regulation samples)
Water System Location*(Required)
Legal address of water system
Select Yes or No
Northing*(Optional)
The north-south component of an UTM coordinate. In Ontario, this may range
from 4614583.73-6302884.09 metres.
Collection Method*(Optional)
GPS unit or other method of location data collection
Map Datum*(Optional)
NAD27 or NAD83
Accuracy*(Optional)
The accuracy of the sample location
Sample Description*(Required)
Indicate if sample is a Raw, Treated or Distribution sample, Cl2 residual
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
125 Resources Road
Etobicoke ON M9P 3V6
2054 (2010/07)
Customer Service Inquiries: 416 235-6030
Customer Service Fax: 416 235-6141
Priority Sample Requests: 416 235-6075
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