Submit the form at least 14 days prior to proposed opening. This is to notify the Medical Officer of Health of the intent to supply water to the users of the following Small Drinking Water System before operation or after a shut down when water has not been supplied to users for more than 60 days as required under Ontario Regulation 319/08 Small Drinking Water Systems. Section 1: Small Drinking Water System (SDWS) Information SDWS Information SDWS Name * System Number * Address * City/Municipality * Postal Code * The SDWS is: * New Re-opening for the season Shut down for alterations or construction Date of proposed opening * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2024202520262027 Water samples are required prior to water being offered to users after a period of closure. Sample results attached: * Yes Pending Attach sample results, if available. Files must be less than 2 MB.Allowed file types: jpg jpeg png txt pdf doc docx ppt. Owner Information Name or Legal Entity * Address * City/Municipality * Postal Code * Phone number * Email address * Section 2 - Responsibilities of Owners and Operators O. Reg. 319/08, s. 6(1) requires the owner of a Small Drinking Water System to designate an operator who has primary responsibility to fulfill the requirements of all sampling, testing, receipt of results, and submission of reports. Designated Operator Information Operator Name * Address * City/Municipality * Postal Code * Email address * Declaration Owner I acknowledge, whether acting as the owner or as a partner/president/signing officer representing the owner, acknowledge that the information provided in this form is accurate and complete. According to the Health Protection and Promotion Act, an operator is defined as the individual(s) responsible for overseeing activities at the Small Drinking Water System. It should be noted that there may be more than one operator at a Small Drinking Water System. The person identified above as the operator for the specified Small Drinking Water System holds primary responsibility for fulfilling the duties of the operator, including sampling, testing, receiving results, and submitting report. * Yes First and last name*Date* First and last name * Date * Month JanFebMarAprMayJunJulAugSepOctNovDec Day 12345678910111213141516171819202122232425262728293031 Year 1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Owner is designated operator * Yes No Declaration Operator I acknowledge that the owner has entrusted me with primary responsibilities for carrying out the operator's duties related to sampling, testing, receiving results, and submitting reports for this small drinking water system. * Yes First and last name*Date * First and last name * Date * Month JanFebMarAprMayJunJulAugSepOctNovDec Day 12345678910111213141516171819202122232425262728293031 Year 1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 The information on this form is collected under the authority of the Health Protection and Promotion Act in accordance with the Municipal Freedom of Information and Protection of Privacy Act and the Personal Health Information Protection Act. This information will be used for the delivery of public health programs and services; the administration of the agency; and the maintenance of healthcare databases, registries and related research, in compliance with legal and regulatory requirements. Any questions about the collection of this information should be addressed to the Chief Privacy Officer at 1-800-265-7293 ext 4339.
