Clear Form
Registration and Laboratory Services
Notification
Ministry of
the Environment
Schools, Private Schools and Day Nurseries (O. Reg. 243/07)
Instructions for ALL FACILITIES
School/Private School/Day Nursery Operators must complete and submit this form to the Ministry prior to submitting
drinking water samples to your contracted licensed laboratory for testing. This form must be re-submitted within 10
days of any change to the information provided on the form as per subsection 5(6) of O. Reg. 243/07.
Please complete this form and fax/email directly to:
Ministry of the Environment
Drinking Water Programs Branch
Fax:
416 314-8716
Email: [email protected]
If you require assistance in completing the form, please call
1 866 793-2588 (toll free).
The most current version of this form is posted on the
Ministry of the Environment’s Drinking Water Ontario
website at www.ontario.ca/drinkingwater
Form Submission Information (please check all that apply)
This is my first submission
I wish to update my facility information
I wish to notify the Ministry that I am changing licensed laboratories for my drinking water testing
I wish to notify the Ministry that I am adding another laboratory for my drinking water testing
Section 1: Schools, Private Schools and Day Nurseries Information
Name of School/Day Nursery
Type
School
SFIS No.
Private School
Day Nursery
SFIS No.
(if known)
License No.
(if known)
Interested Authority
Ministry of Education
Ministry of Children and Youth Services
Other
Drinking Water Information System (DWIS) No. (MOE Number if previously applied for)
Location of School/Day Nursery
Unit No.
Street No.
Street Name
Rural Route
PO Box
Lot/Part/Block/Section
Concession/Plan
City/Town/Municipality
Province
Contact Information
Last Name
First Name
Postal Code
Position
Telephone No. (including area code)
Ext.
Fax No. (including area code)
Email Address
Additional Information (Use this space if you wish to add any additional information)
2001E (PIBS 6271E01) (2011/04)
© Queen’s Printer for Ontario, 2011
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Section 2: School/Day Nursery Operator Information (if different than Section 1)
Legal Name of School/Day Nursery Operator (i.e. school board/private school or individual/corporation who holds the licence for the day nursery)
Operator Contact Name
Unit No.
Street No.
Street Name
Rural Route
PO Box
Lot/Part/Block/Section
City/Town/Municipality
Business Telephone No. (including area code)
Concession/Plan
Province
Ext.
Postal Code
Fax No. (including area code)
Email Address
Section 3: Co-location Information (if applicable)
“Co-located Facilities”:
Facilities are “co-located” if more than one school, private school, or day nursery is served by the same plumbing.
The facilities may be either located in one building (structure) or located in different buildings within one property.
My School/ Private School/ Day Nursery is co-located with another O. Reg. 243/07 facility, as listed below.
Facility Name
Facility DWIS #
Check below if applicable
Yes, we are sharing lead sample results
Facility Name (if more than one)
Facility DWIS #
Yes, we are sharing lead sample results
Facility Name (if more than two)
Facility DWIS #
Yes, we are sharing lead sample results
If more facilities are co-located with your School /Day Nursery, please fill out as many Section 3 of the form as needed and
attach additional sheets.
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2001E (PIBS 6271E01) (2011/04)
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Section 4: Identification of Licensed Laboratory and Lead Testing
Subsection 5 (5) of O. Reg. 243/07 requires the identification of any contracted licensed laboratory(s) hired to
perform lead testing.
The listing of licensed laboratories can be found on: http://www.ontario.ca/drinkingwater/271380.pdf
Please check one of the following:
The facility (identified in section 1) will be sampling as required by O.Reg.243/07 and will be using the
laboratory identified below for lead testing
The facility (identified in section 1) will be sampling as required by O.Reg.243/07 and will be sharing samples
with the co-located facility/facilities as indicated in section 3 of this form and will be using the laboratory
identified below for lead testing
The facility (identified in section 1) does not perform its own sampling because it is sharing sample results
with the co-located facility indicated in section 3 of this form.
Failure to notify the parties in accordance with the Regulation and/or submission of false information constitutes
an offence.
Name/Contact Information of Licensed Laboratory Performing Lead Testing
(Your licensed laboratory can assist with completing this section of the form)
Laboratory Name
Unit No.
Street No.
City/Town/Municipality
Licence Number
Street Name
PO Box
Province
Postal Code
Please specify additional testing identified in MOE (Certificate of Approval, Order or Direction)
I declare that the information provided on this form is accurate.
Prepared by
Last Name
First Name
Signature
Date (yyyy/mm/dd)
Middle Initial
Telephone No. (including area code)
Collection of information on this form by staff of the Drinking Water Management Division on behalf of the Ministry of the Environment is in accordance
with the Safe Drinking Water Act, 2002 (SDWA) and its regulations. The collection, use and dissemination of this information are governed by the
Freedom of Information and Protection of Privacy Act (FOIPPA). The information gathered herein will be used for the purpose of registration and
compliance and may be used for secondary purposes including reporting, investigating and law enforcement under the SDWA and its regulations.
Information on this form, including personal information, may be disclosed to other government agencies including municipalities, public health unit
employees and the Ministry of Health and Long Term Care pursuant to section 42 of FOIPPA for the consistent purpose of administering programs
related to drinking water safety. For questions and concerns, please contact the Ministry of the Environment at 1 866 793-2588.
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2001E (PIBS 6271E) (2011/04)
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